A comparison of two ambulatory blood pressure monitors worn at the same time

Inconsistent Control Status of Office, Home, and Ambulatory Blood Pressure All Taken Using the Same Device: The HI-JAMP Study Baseline Data

BACKGROUND

Inconsistencies between the office and out-of-office blood pressure (BP) values (described as white-coat hypertension or masked hypertension) may be attributable in part to differences in the BP monitoring devices used.

METHODS

We studied consistency in the classification of BP control (well-controlled BP vs. uncontrolled BP) among office, home, and ambulatory BPs by using a validated "all-in-one" BP monitoring device. In the nationwide, general practitioner-based multicenter HI-JAMP study, 2,322 hypertensive patients treated with antihypertensive drugs underwent office BP measurements and 24-hour ambulatory BP monitoring (ABPM), consecutively followed by 5-day home BP monitoring (HBPM), for a total of seven BP measurement days.

RESULTS

Using the thresholds of the JSH2019 and ESC2018 guidelines, the patients with consistent classification of well-controlled status in the office (<140 mmHg) and home systolic BP (SBP) (<135 mmHg) (n = 970) also tended to have well-controlled 24-hour SBP (<130 mmHg) (n = 808, 83.3%). The patients with the consistent classification of uncontrolled status in office and home SBP (n = 579) also tended to have uncontrolled 24-hour SBP (n = 444, 80.9%). Among the patients with inconsistent classifications of office and home BP control (n = 803), 46.1% had inconsistent ABPM-vs.-HBPM out-of-office BP control status. When the 2017 ACC/AHA thresholds were applied as an alternative, the results were essentially the same.

CONCLUSIONS

The combined assessment of the office and home BP is useful in clinical practice. Especially for patients whose office BP classification and home BP classification conflict, the complementary clinical use of both HBPM and ABPM might be recommended.

Diagnostic agreement of masked uncontrolled hypertension detected by ambulatory blood pressure and home blood pressure measured by an all-in-one BP monitoring device: The HI-JAMP study

Masked hypertension is defined by office blood pressure (BP) in the controlled-BP range while out-of-office BP measured by ambulatory BP monitoring (ABPM) and home BP monitoring (HBPM) is in the uncontrolled range. However, diagnosis of masked hypertension may differ if assessed by different out-of-office BP indices. This study aims to investigate the diagnostic agreement of masked uncontrolled hypertension (MUHT) detected by ABPM indices (ABPM-MUHT) and HBPM indices (HBPM-MUHT) using the same all-in-one device (TM2441; A&D Company). The present study enrolled a total of 2322 treated hypertensive patients (males 53.2%, average age 69.2 ± 11.5 years) from the Home-Activity ICT-based Japan Ambulatory Blood Pressure Monitoring Prospective (HI-JAMP) Study, who consecutively underwent office BP monitoring, 24-h ABPM (at 30-min intervals), and 5-day HBPM (twice each morning and evening) using the same device. When out-of-office BP control status was assessed only by 24-h average SBP or by the average of morning and evening SBP, the diagnostic agreement of MUHT detected by ABPM and HBPM was 29.7% among the 445 patients with any type of MUHT. When out-of-office BP indices in each time-window were simultaneously assessed, the diagnostic agreement increased to 40-45.7%. Our results indicated the importance of assessing BPs at various times of day, especially morning hours, for perfect hypertension management. Diagnosis of masked hypertension only by an averaged BP index, without considering specific time-windows, might underestimate cardiovascular risk.

Comparison of 3 Devices for 24-Hour Ambulatory Blood Pressure Monitoring in a Nonclinical Environment Through a Randomized Trial

BACKGROUND

The U.S. Preventive Services Task Force recommends the use of 24-hour ambulatory blood pressure monitoring (ABPM) as part of screening and diagnosis of hypertension. The optimal ABPM device for population-based surveys is unknown.

METHODS

We compared the proportion of valid blood pressure (BP) readings, mean awake and asleep BP readings, differences between awake ABPM readings and initial standardized BP readings, and sleep experience among three ABPM devices. We randomized a convenience sample of 365 adults to 1 of 3 ABPM devices: Welch Allyn Mobil-O-Graph (WA), Sun Tech Classic Oscar2 (STO) and Spacelabs 90227 (SL). Participants completed sleep quality questionnaires on the nights before and during ABPM testing.

RESULTS

The proportions of valid BP readings were not different among the 3 devices (P > 0.45). Mean awake and asleep systolic BP were significantly higher for STO device (WA vs. STO vs. SL: 126.65, 138.09, 127.44 mm Hg; 114.34, 120.34, 113.13 mm Hg; P < 0.0001 for both). The difference between the initial average standardized mercury systolic BP readings and the ABPM mean awake systolic BP was larger for STO device (WA vs. STO. vs. SL: -5.26, -16.24, -5.36 mm Hg; P < 0.0001); diastolic BP mean differences were ~ -6 mm Hg for all 3 devices (P = 0.6). Approximately 55% of participants reported that the devices interfered with sleep; however, there were no sleep differences across the devices (P > 0.4 for all).

CONCLUSION

Most of the participants met the threshold of 70% valid readings over 24 hours. Sleep disturbance was common but did not interfere with completion of measurement in most of the participants.

Evaluation of the Omron HEM-907 automated blood pressure device: comparison with office and ambulatory blood pressure readings

Blood pressure (BP) measured in the clinic is subject to the white coat effect and does not always indicate the 'usual' BP. Ambulatory BP is the current gold standard, but remains inconvenient for routine use. Interest in automated BP, where the healthcare professional is absent from the examination room during BP measurement, is growing, as this reduces the white coat effect and yields BP values that are close to ambulatory readings. The aim of this study was to investigate how well automated office BP (AOBP), measured using the Omron HEM-907 device, compares with observed office BP (OOBP, healthcare professional remains in the examination room) and awake ambulatory BP (AABP) measurements. OOBP, AOBP and AABP were measured in 108 participants, with OOBP and AOBP measurements repeated 1 week later, following a standardised protocol. Average BP readings for visit one were 134 ± 18/77 ± 11 for OOBP, 131 ± 16/75 ± 11 for AOBP, and 133 ± 15/82 ± 12 for AABP. On both visits, automated readings were significantly lower than observed readings for both systolic and diastolic BP (P < 0.001 for both). Automated readings were also significantly lower than ambulatory readings, with a mean difference in systolic/diastolic BP of - 2 ± 11/- 7 ± 10 (P < 0.001 for both), with high correlations between the two modalities (r = 0.75 and r = 0.64, for systolic and diastolic BP, respectively, P < 0.001 for both). AOBP measured by the Omron HEM-907 is not associated with a white coat effect, unlike observed readings, and provides reproducible results and good correlations with ambulatory readings. Automated BP measured using the Omron HEM-907 is, therefore, a useful alternative to observed office readings.

Major Device-Dependence of Measured Hypertensive Status From 24-Hour Ambulatory Blood Pressure Monitoring After Aortic Coarctation Repair

BACKGROUND

Twenty-four-hour (24-hr) ambulatory blood pressure monitoring (ABPM) is often considered the gold standard to detect hypertension. We aimed to determine the short-term progression of 24-hour blood pressure after coarctation repair and to compare ABPM between two different devices.

METHODS

We performed a cross-sectional study using 24-hour ABPM (Oscar 2) in 47 patients aged 16-48 years with previous paediatric coarctation repair and not on antihypertensive medication. Results were compared to a previous ABPM using paired analyses. A subset (10/47, 21%) had an additional previous ABPM performed using a Spacelabs device.

RESULTS

After a mean follow-up of 27±6 years after repair, hypertension and prehypertension on Oscar 2 ABPM was present in 57% (27/47) and 11% (5/47), respectively. Mean follow-up time between Oscar 2 ABPMs was 3.9±1.4 years, and between first Oscar 2 and Spacelabs and between Spacelabs and second Oscar 2 ABPM was 1.4±0.8 and 1.8±0.3 years, respectively. There was no difference in the proportion of hypertensive patients between Oscar 2 ABPMs (55% [26/47] vs. 57% [27/47], p=1.0) but 17 patients (17/47, 36%) had a reclassification of 24-hour ABPM status. Mean 24-hour systolic blood pressure was higher in both Oscar 2 ABPMs compared to Spacelabs (142.4±11.7 vs. 120.4±11.8mmHg, p=0.0001; and 137.4±12.2 vs. 120.4±11.8mmHg, p=0.0001; respectively).

CONCLUSION

There was high intra-device reproducibility of 24-hour ABPM results using an Oscar 2 device but poor inter-device reproducibility in patients with repaired coarctation. Device-specific reference values may be required to ensure reliable 24-hour ABPM interpretation.

Integrating Out-of-Office Blood Pressure in the Diagnosis and Management of Hypertension

Guidelines for the diagnosis and monitoring of hypertension were historically based on in-office blood pressure measurements. However, the US Preventive Services Task Force recently expanded their recommendations on screening for hypertension to include out-of-office blood pressure measurements to confirm the diagnosis of hypertension. Out-of-office blood pressure monitoring modalities, including ambulatory blood pressure monitoring and home blood pressure monitoring, are important tools in distinguishing between normotension, masked hypertension, white-coat hypertension, and sustained (including uncontrolled or drug-resistant) hypertension. Compared to in-office readings, out-of-office blood pressures are a greater predictor of renal and cardiac morbidity and mortality. There are multiple barriers to the implementation of out-of-office blood pressure monitoring which need to be overcome in order to promote more widespread use of these modalities.

Elevated sympathetic activity, endothelial dysfunction, and late hypertension after repair of coarctation of the aorta

BACKGROUND

There is a high prevalence of late hypertension after coarctation repair. The relative contribution of elevated sympathetic tone and endothelial dysfunction to its development is unknown. This study aims to investigate the neural profile of coarctation patients including muscle sympathetic nerve activity testing to directly measure sympathetic nervous activity.

METHODS

Twenty-three patients aged ≥18years with a coarctation repair underwent measurements of clinic and 24-h blood pressures, muscle sympathetic nerve activity, sympathetic and cardiac baroreflex functions, digital endothelial function, and ambulatory arterial stiffness index. Median age at repair was 1.2months (interquartile range: 0-9months). Patients were compared to 17 healthy matched controls.

RESULTS

After 26±5years, 6% (1/18) and 44% (8/18) suffered clinic hypertension and prehypertension, respectively. On 24-h blood pressure monitoring, 15% (3/20) and 20% (4/20) had hypertension and prehypertension, respectively. Coarctation patients had elevated muscle sympathetic nerve activity compared with controls (49.6±24.9 vs. 29.9±14.0 bursts/100 heartbeats, p=0.02), dampened sympathetic baroreflex function (-2.2±2.1 vs. -7.0±5.6 bursts/100heartbeats·mm·Hg^-1, p=0.007), normal cardiac baroreflex function (41.9±30.4 vs. 35.7±21.1ms·mm·Hg^-1, p=0.6), endothelial dysfunction (pulse amplitude tonometry ratio: 0.39±0.32 vs. 0.81±0.50, p=0.004), and increased ambulatory arterial stiffness index (0.46±0.15 vs. 0.29±0.17, p=0.008).

CONCLUSION

After coarctation repair patients have increased muscle sympathetic nerve activity, dampened sympathetic baroreflex response, endothelial dysfunction, and increased ambulatory arterial stiffness index, all of which may contribute to the development of late hypertension.

A study of the VaSera arterial stiffness device in US patients

The cardio-ankle vascular index (CAVI) represents a promising index of arterial stiffness. However, neither the CAVI measure nor its measurement device, the VaSera, have undergone general testing in a North American clinical setting. To begin the process of collecting normal values in the United States, we studied 20 male and 28 female volunteers without reported cardiovascular or renal disease and no history of smoking. Their CAVIs, ankle-brachial indices (ABIs), and four-limb blood pressures were measured in three positions: supine, 7° Trendelenburg, and 7° reverse Trendelenburg. In addition, the ABI function was validated against an established ABI measurement technique. Position was found to affect CAVI and other hemodynamic parameters, indicating that CAVI is not robust to slight positional variations. No differences were found in the blood pressure between arms or legs (interbrachial or interankle), supporting recent findings from meta-analyses and studies but contradicting other work. This study represents an early step in bringing the VaSera device and its CAVI measurement into clinical practice.

Assessing the accuracy of the OMRON HEM-907XL oscillometric blood pressure measurement device in patients with nondialytic chronic kidney disease

The OMRON HEM-907XL is a commercial oscillometric blood pressure (BP) monitor that was used in the Systolic Blood Pressure Intervention Trial (SPRINT), in which 28% of participants had chronic kidney disease (CKD). This study examined the accuracy of the monitor in nondialytic patients with CKD. Eighty-seven patients met inclusion criteria. The authors used a modified Association for the Advancement of Medical Instrumentation (AAMI) protocol, with one observer recording measurements from the monitor and two blinded physicians obtaining simultaneous aneroid values by auscultation. Using AAMI method 1, there was a 2.5±9.5 mm Hg difference in OMRON and aneroid systolic BP, and a -1.6±6.5 mm Hg difference in diastolic BP. Using AAMI method 2, there was a 5.1±7.4 mm Hg difference in systolic BP and a -0.2±5.4 mm Hg difference in diastolic BP. In patients with CKD, the OMRON HEM-907XL appears to be accurate for measuring diastolic BP, but did not perform as well for systolic BP.

High Prevalence of Hypertension and End-Organ Damage Late After Coarctation Repair in Normal Arches

BACKGROUND

To (1) determine the prevalence of hypertension late after coarctation repair in patients with normal-sized transverse arches, and (2) evaluate the potential for end-organ damage related to hypertension after coarctation repair. There are no studies specifically investigating end-organ damage and hypertension after coarctation repair using noninvasive techniques.

METHODS

Eighty-two patients aged 10 years or greater with a coarctation repair and a normal-sized arch operated on between 1978 and 2010, underwent a transthoracic echocardiogram, 24-hour blood pressure (BP) monitoring, and retinal imaging. Median age at repair was 1 year (interquartile range, 0 to 6); 45% (37 of 82) were operated in the first year of life.

RESULTS

After a follow-up of 24 ± 7 years, 27% (22 of 82) and 50% (41 of 82) suffered resting hypertension and resting prehypertension, respectively. On 24-hour BP monitoring, 61% (49 of 80) and 21% (17 of 80) suffered hypertension and prehypertension, respectively. Arch reobstruction (echo gradient > 25 mm Hg) was present in only 15% (12 of 82), and in only 15% (7 of 47) with 24-hour hypertension. Resting hypertension was associated with a smaller central retinal artery equivalent (average width of arterioles) and central retinal vein equivalent (average width of venules) (p = 0.0006 and p = 0.003, respectively). Left ventricular hypertrophy on echocardiography was present in 63% (31 of 49) with 24-hour hypertension compared with only 42% (13 of 31) with normal 24-hour BP (p = 0.06).

CONCLUSIONS

There is a high rate of hypertension late after coarctation repair, even in patients with unobstructed arches. The presence of retinal imaging abnormalities and left ventricular hypertrophy signals the presence of end-organ damage in this young adult population. Regular follow-up with 24-hour BP monitoring is warranted.

Ambulatory blood pressure in chronic kidney disease

Chronic kidney disease (CKD) affects approximately 20 million adults in the United States. Patients with CKD have an increased risk of cardiovascular (CV) disease. Ambulatory blood pressure monitoring (ABPM) provides superior BP measurements when compared to office BP measurements in normotensive, hypertensive and CKD patients. ABPM measurements are often abnormal in CKD, with CKD patients frequently showing an altered circadian rhythm with an increased rate of non-dipping and reverse dipping. The prevalence of non-dippers and reverse-dippers increases progressively as stage of CKD progresses. ABPM has been shown to be a better tool for predicting CV risk, CKD progression, end stage renal disease (ESRD) or death than office-based pressures. ABPM is also additive and adds prognostic value for predicting CKD and CV outcomes when added to estimated glomerular filtration rate (eGFR). Although ABPM is time consuming, it is worth considering, as the data demonstrates that information from ABPM can potentially impact future CV and renal outcomes in patients with CKD.