Accuracy of ambulatory blood pressure monitors

Routine Prenatal Care

The one-size-fits-all model of prenatal care has remained largely unchanged since 1930. New models of prenatal care delivery can improve its efficacy, equity, and experience through tailoring prenatal care to meet pregnant people's medical and social needs. Key aspects of recently developed prenatal care models include visit schedules based on needed services, telemedicine, home measurement of routine pregnancy parameters, and interventions that address social and structural drivers of health. Several barriers that affect the individual, provider, health system, and policy levels must be addressed to facilitate implementation of new prenatal care delivery models.

Ambulatory Blood Pressure Monitoring in Children and Adults Prenatally Exposed to Dexamethasone Treatment

CONTEXT

The clinical use of dexamethasone (DEX) prenatally to reduce virilization of external genitalia in female fetuses with congenital adrenal hyperplasia (CAH) is efficient but still controversial. It remains challenging to prevent the excessive exposure of DEX in unborn healthy babies during the first trimester of pregnancy.

OBJECTIVE

Since endogenous glucocorticoids contribute to the maintenance of blood pressure (BP) and since events during fetal life may program the fetus and affect future metabolic health, the aim of this study was to analyze ambulatory BP measurements in CAH-unaffected children and adults that were prenatally exposed to DEX treatment.

METHODS

Ambulatory BP measurements were analyzed in 33 (16 female) DEX-treated participants aged 5.1 to 26.3 years (19 participants aged ≤ 18 years) and in 54 (28 female) age- and sex-matched apparently healthy controls aged 5.5 to 25.3 years (27 participants aged ≤ 18 years) with ambulatory normotension.

RESULTS

Participants' age, height, weight, and body mass index were similar between the DEX-treated group and the control group. Heart rate, 24-hour BP, pulse pressure, and nighttime dipping did not statistically significantly differ between DEX-treated participants and controls.

CONCLUSION

Our study suggests that prenatal DEX treatment in CAH-unaffected children and adults does not appear to adversely affect ambulatory BP later in life. Our observations need to be confirmed in larger studies.

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

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

Hypertension Among Hemorrhagic Stroke Patients in Northeast China: A Population-Based Study 2017-2019

BACKGROUND We aimed to profile the current epidemiology of hypertension among the survivors of hemorrhagic stroke in northeast China. MATERIAL AND METHODS Our cross-sectional study included 18 796 adults aged 40 years or older and residing in northeast China. Hemorrhagic stroke was identified according to the CT and/or MRI results. Hypertension was defined based on the Chinese hypertension guidelines. RESULTS We identified 208 patients with previous hemorrhagic stroke in this population-based study. The overall prevalence of hypertension in the studied population was 88%. Out of all the survivors of hemorrhagic stroke, 80.9% were aware of their hypertensive condition, 70.5% of the patients were in antihypertensive medications treatment, and only 12% of the patients had their blood pressure under control. Furthermore, only 17.10% of the patients who took hypertensive medications achieved appropriate blood pressure. Calcium channel blockers were more commonly used than other medications. Patients with controlled hypertension had significantly higher percentages of comorbidities when compared to those with uncontrolled hypertension. In our patient sample, the rates of stage 2 and stage 3 hypertension in the hemorrhagic stroke population were 28.8% and 15.9%, respectively, and women had a significantly higher prevalence of stage 3 hypertension when compared with men (21.3% vs. 10.0%, P=0.026). CONCLUSIONS The high prevalence of uncontrolled hypertension and high rates of blood pressure at stages 2 and 3 in patients with prior hemorrhagic stroke indicated a considerable stroke burden in northeast China. Therefore, effective and long-time management of hypertension in stroke survivors should be a priority.

Recommendations and Practical Guidance for performing and reporting validation studies according to the Universal Standard for the validation of blood pressure measuring devices by the Association for the Advancement of Medical Instrumentation/European Society of Hypertension/International Organization for Standardization (AAMI/ESH/ISO)

: In the past 30 years, several organizations have developed protocols for clinical validation of blood pressure measuring devices. An international initiative was recently launched by the US Association for the Advancement of Medical Instrumentation (AAMI), the European Society of Hypertension Working Group on Blood Pressure Monitoring (ESH) and the International Organization for Standardization (ISO), aiming to reach consensus on a universal AAMI/ESH/ISO validation standard. The purpose of this statement by the ESH Working Group on Blood Pressure Monitoring is to provide practical guidance for investigators performing validation studies according to the AAMI/ESH/ISO Universal Standard (ISO 81060-2:2018), to ensure that its stipulations are meticulously implemented and data are fully reported. Thus, this statement provides: a list of key recommendations for validation studies of intermittent non-invasive automated blood pressure measuring devices according to the AAMI/ESH/ISO Universal Standard; practical stepwise guidance for researchers performing these validation studies; a checklist for authors and reviewers of such studies; an example of a complete validation study report.

STRIDE BP international initiative for accurate blood pressure measurement: Systematic review of published validation studies of blood pressure measuring devices

Blood pressure (BP) is a vital sign, and its measurement is essential for diagnosing and treating hypertension. The accuracy of BP monitors is therefore essential, but unfortunately very few devices available on the market have been validated using an established protocol. STRIDE BP (www.stridebp.org) is an international nonprofit organization with the mission to improve the accuracy of BP measurement and the diagnosis of hypertension. It has a prestigious Scientific Advisory Board and operates in affiliation with the European Society of Hypertension, the International Society of Hypertension, and the World Hypertension League. STRIDE BP provides lists of accurate office, ambulatory, and home BP monitors. STRIDE BP performed a systematic review of 419 published validations (270 articles and 260 devices). In these publications, 50 (12%) of the validations were rejected compared with 129 (31%) rejected by STRIDE BP (P < .001). Of 79 validations approved in publications but rejected by STRIDE BP, 7 (9%) were rejected due to device inaccuracy and 72 (91%) due to inadequate study quality (execution, analysis, and reporting). Errors in conducting and reporting published validations must be avoided. Peer review must ascertain that a comprehensive checklist of all aspects of a validation study have been adhered to. The implementation of a Universal Standard for device validation and the global dissemination of information on accurate devices by STRIDE BP are expected to improve the quality and accuracy of BP measurement, which should have a positive impact on the diagnosis and management of hypertension globally.

Point-of-care technologies in heart, lung, blood and sleep disorders from the Center for Advancing Point-of-Care Technologies

Recent advancements in point-of-care technologies have transformed care for patients with heart, lung, blood, and sleep disorders by providing rapid, cost-effective, and accessible solutions to challenges in the detection and management of many health conditions. However, major barriers exist throughout the technology development process that inhibit the actualization of many promising and potentially successful ideas. The Center for Advancing Point of Care Technologies has established a system for supporting further innovation in this field and bridging the gap between initial idea conception and implementation. We highlight current and emerging point-of-care technologies throughout the development spectrum and emphasize the need for a needs-driven model of health technology development that involve appropriate stakeholders in the process.

Measurement of Blood Pressure in Humans: A Scientific Statement From the American Heart Association

The accurate measurement of blood pressure (BP) is essential for the diagnosis and management of hypertension. This article provides an updated American Heart Association scientific statement on BP measurement in humans. In the office setting, many oscillometric devices have been validated that allow accurate BP measurement while reducing human errors associated with the auscultatory approach. Fully automated oscillometric devices capable of taking multiple readings even without an observer being present may provide a more accurate measurement of BP than auscultation. Studies have shown substantial differences in BP when measured outside versus in the office setting. Ambulatory BP monitoring is considered the reference standard for out-of-office BP assessment, with home BP monitoring being an alternative when ambulatory BP monitoring is not available or tolerated. Compared with their counterparts with sustained normotension (ie, nonhypertensive BP levels in and outside the office setting), it is unclear whether adults with white-coat hypertension (ie, hypertensive BP levels in the office but not outside the office) have increased cardiovascular disease risk, whereas those with masked hypertension (ie, hypertensive BP levels outside the office but not in the office) are at substantially increased risk. In addition, high nighttime BP on ambulatory BP monitoring is associated with increased cardiovascular disease risk. Both oscillometric and auscultatory methods are considered acceptable for measuring BP in children and adolescents. Regardless of the method used to measure BP, initial and ongoing training of technicians and healthcare providers and the use of validated and calibrated devices are critical for obtaining accurate BP measurements.

Validation of the TM-2441 ambulatory blood pressure measurement device according to the ISO 81060-2: 2013 standard

OBJECTIVE

The aim of this study was to validate the TM-2441 ambulatory blood pressure monitoring (ABPM) device using the ISO 81060-2:2013 standard.

PARTICIPANTS AND METHODS

Participants were healthy individuals aged more than 12 years who were recruited from among the outpatients and volunteers of Jichi Medical University (Tochigi, Japan). The same-arm sequence protocol (clinical validation) and the opposite-limb simultaneous method (ambulatory validation) from the ISO 81060-2:2013 standard were used.

RESULTS

One hundred and seven participants were enrolled; 85 participated in the clinical validation and 35 participated in the ambulatory validation (13 participants were included in both validation protocols). The TM-2441 device performed well against the standard in both the clinical and ambulatory validations; the mean and SD values for the differences between device and observed systolic and diastolic blood pressure values in both tests fulfilled criterion 1 and criterion 2 of the standard. The Bland-Altman plots did not show any systematic variation in the error.

CONCLUSION

The TM-2441 ABPM device was accurate and fulfilled all ISO 81060-2:2013 standard requirements for ABPM determination in adults. It is therefore suitable for use for ABPM in adults with hypertension.

Out of Office Blood Pressure Measurement in Pregnancy and the Postpartum Period

PURPOSE

Hypertensive disorders of pregnancy are increasing in prevalence and associated with significant maternal and perinatal morbidity and mortality.

RECENT FINDINGS

Increased emphasis has been placed recently on the use of out-of-office (i.e., home and ambulatory) blood pressure (BP) monitoring to diagnose and manage hypertension in the general population. Current guidelines offer limited recommendations on the use of out-of-office BP monitoring during pregnancy and postpartum. This review will discuss the recent literature on BP measurement outside of the office and its use for screening, diagnosis, and treatment in pregnancy and postpartum, and will illuminate areas for future research.

Validation protocols for blood pressure measuring devices in the 21st century

Blood pressure (BP) is a vital sign and the essential measurement for the diagnosis of hypertension. Therefore, its accurate measurement is a key element for the evaluation of many medical conditions and for the reliable diagnosis and efficient treatment of hypertension. In the last 3 decades prestigious organizations, such as the US Association for the Advancement of Medical Instrumentation (AAMI), the British Hypertension Society, the European Society of Hypertension (ESH) Working Group on BP Monitoring, and the International Organization for Standardization (ISO), have developed protocols for clinical validation of BP measuring devices. All these initiatives aim to standardize validation procedures and establish minimum accuracy standards for BP monitors. Unfortunately, only a few of the BP measuring devices available on the market have been subjected to independent validation using one of these protocols. Recently, the AAMI, ESH, and ISO experts agreed to develop a single universally acceptable standard (AAMI/ESH/ISO), which will replace all previous protocols. This major international initiative has been undertaken to best serve the needs of patients with hypertension, a public interested in cardiovascular health, practicing physicians, scientific researchers, regulatory bodies, and manufacturers. There is an urgent need to influence regulatory authorities throughout the world to make it mandatory for all BP measuring devices to have undergone independent validation before approval for marketing. Efforts need to be intensified to improve the accuracy of BP measuring devices, further optimize the validation procedure, and ensure that objective and unbiased validation data become available.

A universal standard for the validation of blood pressure measuring devices: Association for the Advancement of Medical Instrumentation/European Society of Hypertension/International Organization for Standardization (AAMI/ESH/ISO) Collaboration Statement

: In the last 30 years, several organizations, such as the US Association for the Advancement of Medical Instrumentation (AAMI), the British Hypertension Society, the European Society of Hypertension (ESH) Working Group on Blood Pressure (BP) Monitoring and the International Organization for Standardization (ISO) have developed protocols for clinical validation of BP measuring devices. However, it is recognized that science, as well as patients, consumers and manufacturers would be best served if all BP measuring devices were assessed for accuracy according to an agreed single validation protocol that had global acceptance. Therefore, an international initiative was taken by AAMI, ESH and ISO experts who agreed to develop a universal standard for device validation. This statement presents the key aspects of a validation procedure, which were agreed by the AAMI, ESH and ISO representatives as the basis for a single universal validation protocol. As soon as the AAMI/ESH/ISO standard is fully developed, this will be regarded as the single universal standard and will replace all other previous standards/protocols.

A Universal Standard for the Validation of Blood Pressure Measuring Devices: Association for the Advancement of Medical Instrumentation/European Society of Hypertension/International Organization for Standardization (AAMI/ESH/ISO) Collaboration Statement

In the past 30 years, several organizations, such as the US Association for the Advancement of Medical Instrumentation (AAMI), the British Hypertension Society, the European Society of Hypertension (ESH) Working Group on Blood Pressure (BP) Monitoring, and the International Organization for Standardization (ISO), have developed protocols for clinical validation of BP measuring devices. However, it is recognized that science, as well as patients, consumers, and manufacturers, would be best served if all BP measuring devices were assessed for accuracy according to an agreed single validation protocol that had global acceptance. Therefore, an international initiative was taken by the AAMI, ESH, and ISO experts who agreed to develop a universal standard for device validation. This statement presents the key aspects of a validation procedure, which were agreed by the AAMI, ESH, and ISO representatives as the basis for a single universal validation protocol. As soon as the AAMI/ESH/ISO standard is fully developed, this will be regarded as the single universal standard and will replace all other previous standards/protocols.

Accuracy of Blood Pressure Measurement Devices in Pregnancy: A Systematic Review of Validation Studies

The accurate measurement of blood pressure (BP) in pregnancy is essential to guide medical decision making that affects both mother and fetus. The aim of this systematic review was to determine the accuracy of ambulatory, home, and clinic BP measurement devices in pregnant women. We searched Ovid MEDLINE, The Cochrane Library, EMBASE, CINAHL EBSCO, ClinicalTrials.gov, International Clinical Trials Registry Platform, and dabl from inception through August 3, 2017 for articles that assessed the validity of an upper arm BP measurement device against a mercury sphygmomanometer in pregnant women. Two independent investigators determined eligibility, extracted data, and adjudicated protocol violations. From 1798 potential articles identified, 41, that assessed 28 devices, met the inclusion criteria. Most articles (n=32) followed a standard or modified American National Standards Institute/Association for the Advancement of Medical Instrumentation/International Organization for Standardization, British Hypertension Society, or European Society of Hypertension validation protocol. Several articles described the results of validation studies performed on >1 device (n=7) or in >1 population of pregnant women (n=12), comprising 64 pairwise validity assessments. The device was validated in 61% (32 of 52) of studies which used a standard or modified protocol. Only 34% (11 of 32) of the studies wherein the device was successfully validated were performed without a protocol violation. Given the implications of inaccurate BP measurement in pregnant women, healthcare providers should be aware of and try to use the BP measurement devices which have been properly validated in this population.

Validation of the custo screen pediatric blood pressure monitor according to the European Society of Hypertension International Protocol revision 2010

The purpose of the study was to validate the ambulatory blood pressure monitoring (ABPM) device custo screen pediatric in children aged 3 to 12 years according to the International Protocol of the European Society of Hypertension (ESH-IP revision 2010). Thirty-three children were included and systolic and diastolic blood pressure measurements were performed according to the ESH-IP. The protocol was modified for children considering data from the German Health Interview and Examination Survey for Children and Adolescents (KIGGS). The custo screen pediatric met all the requirements of the ESH-IP. The mean difference between the test device and the reference was -1.4 ± 3.0 mmHg for systolic blood pressure (SBP) and -0.7 ± 3.2 mmHg for diastolic blood pressure (DBP). For SBP and DBP, all 99 measurements were within the absolute difference of 10 mmHg between the test device and the reference. As to part 2 of the protocol, for DBP in all subjects, two out of three measurements were within 5 mmHg between the device and the standard, whereas for SBP in 32 of 33 subjects, two out of three measurements were within this range.

CONCLUSION

The custo screen pediatric met all criteria of the ESH-IP review 2010, modified for children from 3 to about 12 years, and can be recommended for ABPM in children. What is Known: • Validation of blood pressure measuring devices is essential to provide patients with an accurate blood pressure measuring device. • The majority of devices has not been validated in children. What is New: • Prior to the present validation, study protocol adjustments of ESH-IP review 2010 for children were defined according to German Health Interview and Examination Survey for Children and Adolescents 2013 (KIGGS). • The custo screen pediatric test device met all criteria of ESH-IP revision 2010, modified for children, and can be recommended for ABPM in children aged 3 to about 12 years.

Cost-effectiveness of ambulatory blood pressure monitoring in the management of hypertension

INTRODUCTION AND OBJECTIVES

The prevalence of hypertension in Portugal is between 29.1% and 42.2%. International studies show that 13% of individuals have masked hypertension and 13% of diagnoses based on office blood pressure measurements are in fact white coat hypertension. More sensitive and specific blood pressure measuring methods could avoid costs associated with misdiagnosis. The aim of this study was to review the cost-effectiveness of ambulatory blood pressure monitoring (ABPM) compared to other methods in the management of hypertension.

METHODS

We performed a literature search in CMA Infobase, Guidelines Finder, National Guideline Clearinghouse, Bandolier, BMJ Clinical Evidence, the Cochrane Library, DARE, Medline, the Trip Database, SUMSearch and Índex das Revistas Médicas Portuguesas. We researched articles published between January 2005 and August 2015 in Portuguese, English and Spanish, using the MeSH terms "Hypertension", "Blood Pressure Monitoring, Ambulatory" and "Cost-Benefit Analysis" and the Portuguese search terms "Hipertensão", "Monitorização Ambulatorial da Pressão Arterial" and "Análise Custo-Benefício". Levels of evidence and grades of recommendation were attributed according to the Oxford Centre for Evidence-Based Medicine scale.

RESULTS

Five hundred and twenty-five articles were identified. We included five original studies and one clinical practice guideline. All of them state that ABPM is the most cost-effective method. Two report better blood pressure control, and a Portuguese study revealed a saving of 23%.

CONCLUSIONS

The evidence shows that ABPM is cost-effective, avoiding iatrogenic effects and reducing expenditure on treatment (grade of recommendation B). The included studies provide a solid basis, but further evidence of reproducibility is needed in research that is not based mainly on analytical models.

The use of ambulatory blood pressure measurement

Measurement of ambulatory blood pressure is recommended by the National Institute for Health and Care Excellence guidelines to confirm the diagnosis of hypertension in the UK. This article describes the use of ambulatory devices, and discusses the benefits and disadvantages of their use in clinical practice.

Chronic Management of Hypertension after Stroke: The Role of Ambulatory Blood Pressure Monitoring

Hypertension is the most important potentially reversible risk factor for stroke in all age groups; high blood pressure (BP) is also associated with increased risk of recurrent stroke in patients who have already had an ischemic or hemorrhagic event. Twenty-four hour ambulatory BP monitoring (ABPM) has become an important tool for improving the diagnosis and management of hypertension, and is increasingly used to assess patients with hypertension. Nevertheless, although ABPM devices are increasingly used for assessment of hypertension, their value in the chronic management of hypertension in patients with stroke has not been systematically studied. In fact, among large-scale randomized trials for secondary stroke prevention, only the Morbidity and Mortality After Stroke, Eprosartan Compared With Nitrendipine for Secondary Prevention trial included 24-hour ABPM. ABPM has demonstrated chronic disruption of the circadian rhythm of BP after acute phase of stroke and has shown higher sensitivity compared to office BP in evaluating the effectiveness of antihypertensive treatment among stroke survivors. High 24-hour BP is an independent predictor for cerebrovascular events, brain microbleeds, and subsequent development of dementia. Nevertheless, although stroke care guidelines endorse the importance of hypertension management, the specific role of ABPM among stroke survivors after the acute phase of disease has not been established. Further studies are needed to clarify whether routine application of ABPM among these patients should be recommended.

Ambulatory Assessment in the Research on Aging: Contemporary and Future Applications

Older adults have surprisingly high levels of well-being, which has been referred to as a paradox in the past. Improved emotion regulation has been suggested to underlie these high levels of well-being. Later life is also a period with enhanced exposure to critical life events, and this comes with risks. During such times, and towards the end of life, emotional well-being may and eventually does decline. We suggest that ambulatory assessment (AA) is ideally suited for the investigation of the above phenomena and for intervention purposes. More precisely, AA can be used to thoroughly examine within-person processes of emotion regulation, including the multiple levels on which emotions occur (physiology, experience, behavior, context, and nonverbal expressions). It thereby provides a basis for understanding competent emotion regulation, the well-being paradox, and emotionally critical periods. Such insights can be utilized to detect person-specific critical periods and for designing immediate person-specific interventions. Although this is still a vision, the benefits of such an approach seem invaluable. The major part of this paper is organized around three general principles that we suggest to further tap the potential of AA in aging research, namely (1) identify within-subject processes and their relations to important life outcomes; (2) capitalize on the full scope of AA technology via multivariate assessments, and (3) combine real-time monitoring with real-time interventions.

Validation of the custo screen 400 ambulatory blood pressure-monitoring device according to the European Society of Hypertension International Protocol revision 2010

Objective

The aim of the present study was to validate the custo screen 400 ambulatory blood pressure-monitoring (ABPM) device according to the 2010 International Protocol revision of the European Society of Hypertension (ESH-IP). The device can be used for ABPM for up to 72 hours.

Materials and methods

Systolic and diastolic blood pressure (SBP and DBP, respectively) were sequentially measured in 33 adult subjects (13 males and 20 females) and compared with a standard mercury sphygmomanometer (two observers). A total of 99 comparison pairs were obtained.

Results

The custo screen 400 met the requirements of parts 1 and 2 of the ESH-IP revision 2010. The mean difference between the device and reference sphygmomanometer readings was −0.5±4.5 mmHg for SBP and −0.1±3.3 mmHg for DBP. All but one measurement were within the absolute difference of 10 mmHg between the device and the observers for SBP and DBP. The number of absolute differences between the device and the observers within a range of 5 mmHg was 84 of 99 readings for SBP, and 93 of 99 readings for DBP.

Conclusion

The custo screen 400 ABPM device met the requirements of the 2010 ESH-IP revision, and hence can be recommended for ABPM in adults. To our knowledge, the custo screen 400 is the first device to pass the revised ESH-IP 2010.

Use of ambulatory blood pressure monitoring to guide hypertensive therapy

OPINION STATEMENT

With the advent of noninvasive 24-hour ambulatory blood pressure monitoring (ABPM), clinicians have access to a wealth of individualized data for the hypertensive patient. This has led to a greater understanding of the pathophysiology of hypertension and its complications. This tool has provided more precise diagnostic criteria for hypertension and helped discover those with white coat and masked hypertension. Patterns noted on ABPM and correlated with outcomes have allowed for more accurate identification of patients at high risk of cardiovascular (CV) events, and have offered an additional prognostic tool. In addition, ABPM allows for the assessment of the efficacy and adequacy of blood pressure treatment. In the current paper, we will describe the essential components of ABPM, review the evidence detailing the prognostic information that can be derived from its use, highlight clinical scenarios wherein ABPM can offer invaluable diagnostic information, and describe applications of ABPM that evaluate the efficacy of treatment of the hypertensive patient.