Multiple clinic and home blood pressure measurements versus ambulatory blood pressure monitoring

Factors Affecting the Level of Adherence to Hypertension Medications: A Cross-Sectional Study Using the Hill-Bone Questionnaire

Background

The adherence to antihypertensive therapy plays a significant role in determining the clinical outcomes of hypertension. We aim to evaluate the level of adherence to antihypertensive medications among patients and to assess the effect of different sociodemographic factors on the level of adherence using the Hill-Bone scale for indirect assessment.

Methodology

In this cross-sectional study, we utilized a validated, face-to-face interview questionnaire to collect data on sociodemographic characteristics, participants' attitudes, and disease knowledge. The Hill-Bone questionnaire was employed to assess treatment adherence. The statistical analysis was conducted using SPSS version 28.0, where mean, standard deviation, and range were utilized for variability analysis.

Results

A total of 390 patients were included in this study. The sample comprised 56.9% of females and 56.4% of participants aged 60 years or older. Approximately 80% of participants were currently married, and 46.7% had a higher education level. The average Hill-Bone CHBPTS score was 21.23± 4.95 and indicated good adherence in 63.8% of participants. The findings showed that several factors were significantly associated with higher adherence rates, including older age (COR = 3.41, 95% CI = 1.10-10.54, p = 0.03), higher educational level (COR = 1.72, 95% CI = 1.05-2.83, p = 0.03), regular blood pressure monitoring (COR = 1.90, 95% CI = 1.10-3.30, p = 0.03), and knowledge about their medications (COR = 2.12, 95% CI = 1.14-3.94, p = 0.02).

Conclusion

The medication adherence within our population falls below the desired level. Enhanced counselling and further research are necessary to identify additional factors influencing adherence and develop effective strategies for promoting adherence to antihypertensive medications.

The Importance of Out-of-Office Blood Pressure Measurement, as Highlighted by the Correlation with Left Ventricular Hypertrophy in an Untreated Hypertensive Population

Background and Objectives: Hypertensive heart disease, especially left ventricular hypertrophy (LVH), is considered to be one of the main types hypertension-mediated organ damage. Hence, the purpose of this study was to examine which method of measuring BP (office BP measurement (OBPM), 24 h ambulatory BP monitoring (ABPM), or home BP monitoring (HBPM)), can be better correlated with echocardiographic LVH in the untreated hypertensive population. Materials and Methods: This study's population consisted of 202 patients 58 ± 15 years old (40.8% males). All patients reported elevated home BP measurements for at least 3 months, but they had never been treated before for hypertension. Office and out-of-office BP measurements, including ABPM on a usual working day and seven-day HBPM, as well as 2D echocardiography, were performed. Results: In the univariate analysis, LVH was associated (p < 0.05) with a mean 24 h systolic BP (OR: 1.93, CI: 1.29-2.91), a mean 24 h diastolic BP (OR: 1.30, CI: 1.16-1.80), ambulatory daytime systolic (OR: 1.11, CI:1.01-1.82) and diastolic BP (OR: 1.13, CI:1.09-1.17), ambulatory nighttime systolic BP (OR: 2.11, CI: 1.04-4.31), and mean home systolic BP (OR: 1.05, CI:1.01-1.12). Pearson's correlation analysis showed a significant correlation between the LV mass index and the mean 24 h systolic BP (r = 0.58, p < 0.05), daytime systolic BP (r = 0.59, p < 0.05), and nighttime systolic BP (r = 0.57, p < 0.05). Most of the population with confirmed LVH presented confirmed hypertension (based on ABPM, 48.1% or HBPM, 40%). The second most dominant phenotype was masked hypertension (ABPM, 32.7% and HBPM, 23.7%). The majority (59.3%) had non-dipping status, 20.4% had a reverse dipping pattern, 13% had a dipping pattern, and only 7.3% had extreme dipping BP. Conclusions: Out-of-office BP measurement devices seemed to be superior compared to in-office. This advantage is highlighted by better correlations in the identification of LVH as well as the diagnosis of masked hypertension, a condition also highly correlated with LVH.

Status of ambulatory blood pressure monitoring and home blood pressure monitoring for the diagnosis and management of hypertension in the US: an up-to-date review

The diagnosis and management of hypertension has been based on the measurement of blood pressure (BP) in the office setting. However, data have demonstrated that BP may substantially differ when measured in the office than when measured outside the office setting. Higher out-of-office BP is associated with increased cardiovascular risk independent of office BP. Ambulatory BP monitoring (ABPM) and home BP monitoring (HBPM) are validated approaches for out-of-office BP measurement. In the 2015 and 2021 United States Preventive Services Task Force (USPSTF) reports on screening for hypertension, ABPM was recommended as the reference standard for out-of-office BP monitoring and for confirming an initial diagnosis of hypertension. This recommendation was based on data from more published studies of ABPM vs. HBPM on the predictive value of out-of-office BP independent of office BP. Therefore, HBPM was recommended as an alternative approach when ABPM was not available or well tolerated. The 2017 American College of Cardiology (ACC)/American Heart Association (AHA) BP guideline recommended ABPM as the preferred initial approach for detecting white-coat hypertension and masked hypertension among adults not taking antihypertensive medication. In contrast, HBPM was recommended as the preferred initial approach for detecting the white-coat effect and masked uncontrolled hypertension among adults taking antihypertensive medication. The current review provides an overview of ABPM and HBPM in the US, including best practices, BP thresholds that should be used for the diagnosis and treatment of hypertension, barriers to widespread use of such monitoring, US guideline recommendations for ABPM and HBPM, and data supporting HBPM over ABPM.

Differences of blood pressure measured at clinic versus at home in the morning and in the evening in Europe and Asia: A systematic review and meta-analysis

Numerous studies have indicated that there might be great differences among different populations in Europe and Asia in terms of home morning and evening blood pressure (BP). Thus, the authors performed a systematic review to determine the quantitative differences of BP measured at clinic versus at home in the morning and in the evening in Europe and Asia. PubMed, Embase, and Scopus databases were searched up to October 2021. Studies that compared clinic BP with home morning and (or) home evening BP in European and Asian populations were included. A random effect model was applied to pool the differences between clinic BP and home morning/evening BP. Thirty‐five studies, for a total of 49 432 patients, were included in this meta‐analysis. Mean clinic systolic blood pressure (SBP) values were significantly higher than home morning SBP values by 3.79 mmHg (95% CI, 2.77–4.80). The differences were much larger in Europe [(6.53 mmHg (95% CI, 4.10–8.97)] than in Asia [(2.70 mmHg (95% CI, 1.74–3.66)], and the region was a significant predictor for the differences. Mean clinic SBP values were also significantly higher than home evening SBP values by 6.59 mmHg (95% CI, 4.98–8.21). The differences were much smaller in Europe [5.85 mmHg (95% CI, 3.24–8.45)] than in Asia [7.13 mmHg (95% CI, 4.92–9.35)], while age and clinic SBP might contribute to it. Our findings showed that the difference between clinic and home morning SBP was much larger in European than Asian populations, whereas the difference between clinic and home evening SBP was the opposite. The differing characteristics of the region, ethnic, age, and clinic BP might explain the diversities.

Effect of Reducing Sedentary Behavior on Blood Pressure (RESET BP): Rationale, design, and methods

Sedentary behavior (SB) has recently been recognized as a strong risk factor for cardiovascular disease, with new guidelines encouraging adults to 'sit less, move more.' Yet, there are few randomized trials demonstrating that reducing SB improves cardiovascular health. The Effect of Reducing Sedentary Behavior on Blood Pressure (RESET BP) randomized clinical trial addresses this gap by testing the effect of a 3-month SB reduction intervention on resting systolic BP. Secondary outcomes include other BP measures, pulse wave velocity, plasma renin activity and aldosterone, and objectively-measured SB (via thigh-mounted activPAL) and physical activity (via waist-worn GT3X accelerometer). RESET BP has a targeted recruitment of 300 adults with desk jobs, along with elevated, non-medicated BP (systolic BP 120-159 mmHg or diastolic BP 80-99 mmHg) and physical inactivity (self-reported aerobic physical activity below recommended levels). The multi-component intervention promotes 2-4 fewer hours of SB per day by replacing sitting with standing and light-intensity movement breaks. Participants assigned to the intervention condition receive a sit-stand desk attachment, a wrist-worn activity prompter, behavioral counseling every two weeks (alternating in-person and phone), and twice-weekly automated text messages. Herein, we review the study rationale, describe and evaluate recruitment strategies based on enrollment to date, and detail the intervention and assessment protocols. We also document our mid-trial adaptations to participant recruitment, intervention deployment, and outcome assessments due to the intervening COVID-19 pandemic. Our research methods, experiences to date, and COVID-specific accommodations could inform other research studying BP and hypertension or targeting working populations, including those seeking remote methods.

Safety and efficacy of stenting for aortic arch hypoplasia in patients with coarctation of the aorta

Background

Despite a successful repair procedure for coarctation of the aorta (CoA), up to two-thirds of patients remain hypertensive. CoA is often seen in combination with abnormal aortic arch anatomy and morphology. This might be a substrate for persistent hypertension. Therefore, we performed endovascular aortic arch stent placement in patients with CoA and concomitant aortic arch hypoplasia or gothic arch morphology. The goal of this retrospective analysis was to investigate the safety and efficacy of aortic arch stenting.

Methods

A retrospective analysis was performed in patients who underwent stenting of the aortic arch at the University Medical Center Utrecht. Measurements collected included office blood pressure, use of antihypertensive medication, invasive peak-to-peak systolic pressure over the arch, and aortic diameters on three-dimensional angiography. Data on follow-up were obtained at the date of most recent outpatient visit.

Results

Twelve patients underwent stenting of the aortic arch. Mean follow-up duration was 14 ± 11 months. Mean peak-to-peak gradient across the arch decreased from 39 ± 13 mm Hg to 7 ± 8 mm Hg directly after stenting (p < 0.001). There were no major procedural complications. Mean systolic blood pressure decreased from 145 ± 16 mm Hg at baseline to 128 ± 9 mm Hg at latest follow-up (p = 0.014).

Conclusion

This retrospective study shows that stenting of the aortic arch is successful when carried out in a state-of-the-art manner. A direct optimal angiographic and haemodynamic result was shown. No major complications occurred during or after the procedure. At short- to medium-term follow-up a decrease in mean systolic blood pressure was observed.

Relationships among clinic, home, and ambulatory blood pressures with small vessel disease of the brain and functional status in older people with hypertension

BACKGROUND

Subcortical small vessel disease, represented as white matter hyperintensity (WMH) on magnetic resonance images (MRI) is associated with functional decline in older people with hypertension. We evaluated the relationships of clinic and out-of-office blood pressures (BP) with WMH and functional status in older persons.

METHODS

Using cross-sectional data from 199 older study participants enrolled in the INFINITY trial, we analyzed the clinic, 24-hour ambulatory, and home BPs and their relationships with WMH burden and mobility and cognitive outcomes.

RESULTS

Volume of WMH was associated with clinic and 24-hour ambulatory systolic BP but not home systolic BP. The mobility measure, supine-to-sit time, had a significant association with 24-hour systolic BP and pulse pressure but not with diastolic BP or values obtained by home BP. Cognitive measures of processing speed (Trails Making Test Part A and the Stroop Word Test) were significantly associated with 24-hour systolic BP, but not clinic and home BPs.

CONCLUSION

These data demonstrate that ambulatory BP measurements in older people are more strongly associated with WMH and certain measures of functional status compared to home BP measurements. Hence, home BP may not be a useful substitute for ambulatory BP for assessing subcortical small vessel disease and its consequences. Further longitudinal analyses comparing clinic and various types of out-of-office BP measures with small vessel brain disease are needed. Clinicaltrials.gov identifier: NCT01650402.

Effect of stent implantation on blood pressure control in adults with coarctation of the aorta

BACKGROUND

Stenting of coarctation of the aorta (CoA) generally results in good angiographic results and a decrease in transcoarctation pressure gradient. However, effect on blood pressure control is less clear. The goal of the current retrospective analysis was to investigate the effects of CoA stenting on blood pressure control.

METHODS

A retrospective analysis was conducted in consecutive adult patients with a CoA who underwent a percutaneous intervention at one of the three participating hospitals. Measurements included office blood pressure, invasive peak-to-peak systolic pressure over the CoA, diameter of the intima lumen at the narrowest part of the CoA and use of medication. The follow-up data were obtained, based on the most recent examination date.

RESULTS

There were 26 native CoA and 17 recurrent CoAs (total n = 43). Seven of them underwent two procedures. Mean peak-to-peak gradient decreased from 27 mmHg to 3 mmHg (p < 0.001), and minimal diameter increased from a mean of 11 mm to 18 mm (p < 0.001). Mean systolic blood pressure decreased from 151 ± 18 mmHg to 135 ± 19 mmHg at first follow-up of 3.8 ± 1.9 months and 137 ± 22 mmHg at latest follow-up of 19.5 ± 10.9 months (p = 0.001 and p = 0.009, compared to baseline, respectively). The total number of hypertensive patients decreased from 74% to 27% at latest follow-up. No significant change in antihypertensive medication was observed.

CONCLUSION

A clinically significant decrease in systolic blood pressure of approximately 16 mmHg was shown after (re)intervention in CoA patients, which sustained at follow-up. This sustained decrease of blood pressure can be expected to lead to less future adverse cardiovascular events.

Including pork in the Mediterranean diet for an Australian population: Protocol for a randomised controlled trial assessing cardiovascular risk and cognitive function

BACKGROUND

The Mediterranean diet is characterised by the high consumption of extra virgin olive oil, fruits, vegetables, grains, legumes and nuts; moderate consumption of fish, poultry, eggs and dairy; and low consumption of red meat and sweets. Cross sectional, longitudinal and intervention studies indicate that a Mediterranean diet may be effective for the prevention of cardiovascular disease and dementia. However, previous research suggests that an Australian population may find red meat restrictions difficult, which could affect long term sustainability of the diet.

METHODS

This paper outlines the protocol for a randomised controlled trial that will assess the cardiovascular and cognitive benefits of a Mediterranean diet modified to include 2-3 weekly serves of fresh, lean pork. A 24-week cross-over design trial will compare a modified Mediterranean diet with a low-fat control diet in at-risk men and women. Participants will follow each of the two diets for 8 weeks, with an 8-week washout period separating interventions. Home measured systolic blood pressure will be the primary outcome measure. Secondary outcomes will include body mass index, body composition, fasting blood lipids, C-reactive protein, fasting plasma glucose, fasting serum insulin, erythrocyte fatty acids, cognitive function, psychological health and well-being, and dementia risk.

DISCUSSION

To our knowledge this research is the first to investigate whether an alternate source of protein can be included in the Mediterranean diet to increase sustainability and feasibility for a non-Mediterranean population. Findings will be significant for the prevention of cardiovascular disease and age-related decline, and may inform individuals, clinicians and public health policy.

TRIAL REGISTRATION

ACTRN12616001046493 . Registered 5 August 2016.

Difference in evening home blood pressure between before dinner and at bedtime in Japanese elderly hypertensive patients

The authors evaluated the differences between evening home blood pressure (HBP) readings taken before dinner and those taken at bedtime, which were documented in a European and a Japanese guideline, respectively. Forty-eight patients (mean age, 76.4 years) measured their evening HBP twice each day (two measurements both before dinner and at bedtime) for 14 days. The authors defined the at-bedtime (B) minus the before-dinner (D) systolic HBP as the B-D difference. The mean B-D difference was -8.7 mm Hg (P<.001). The depressor effect of bathing was significantly prolonged for 120 minutes. The B-D difference with alcohol consumption was significantly greater than that without alcohol. In the linear mixed model analysis, time after bathing ≤120 minutes and alcohol consumption were significantly associated with the B-D difference after adjustment with covariates. There was a marked difference between evening HBP values. When patients' evening HBP is measured according to the guidelines, their daily activities should be considered.

A Mediterranean Diet to Improve Cardiovascular and Cognitive Health: Protocol for a Randomised Controlled Intervention Study

The Mediterranean diet has demonstrated efficacy for improving cardiovascular and cognitive health. However, a traditional Mediterranean diet delivers fewer serves of dairy and less dietary calcium than is currently recommended in Australia, which may limit long-term sustainability. The present study aims to evaluate whether a Mediterranean diet with adequate dairy and calcium can improve cardiovascular and cognitive function in an at-risk population, and thereby reduce risk of cardiovascular disease (CVD) and cognitive decline. A randomised, controlled, parallel, crossover design trial will compare a Mediterranean diet supplemented with dairy foods against a low-fat control diet. Forty participants with systolic blood pressure above 120 mmHg and at least two other risk factors of CVD will undertake each dietary intervention for eight weeks, with an eight-week washout period between interventions. Systolic blood pressure will be the primary measure of interest. Secondary outcomes will include measures of cardiometabolic health, dietary compliance, cognitive function, assessed using the Cambridge Neuropsychological Test Automated Battery (CANTAB), psychological well-being and dementia risk. This research will provide empirical evidence as to whether the Mediterranean diet can be modified to provide recommended dairy and calcium intakes while continuing to deliver positive effects for cardiovascular and cognitive health. The findings will hold relevance for the field of preventative healthcare and may contribute to revisions of national dietary guidelines.

Effects of lercanidipine hydrochloride versus felodipine sustained-release on day-to-day home blood pressure variability

OBJECTIVE

The objective of this study was to compare the effectiveness of lercanidipine with felodipine in patients with mild-to-moderate hypertension on day-to-day home blood pressure variability.

METHODS

This is a sub-study of a multicenter, randomized, open-label, parallel group and active controlled clinical trial. Hypertensive patients aged 18-75 (i.e. diastolic blood pressure ≥90 mmHg and <110 mmHg; systolic blood pressure ≥140 mmHg and <180 mmHg) and 24 h mean BP >130/80 mmHg) were eligible for this study. During the study, blood pressure (BP) and heart rate (HR) were recorded. The day-to-day BP variability (BPV) and HR variability (HRV) were obtained by the standard deviation (SD) of daily BP/HR average (of six readings) in 7 days.

RESULTS

There were 186 patients (89 and 97 patients in the lercanidipine and felodipine groups, respectively) included in this study. Lercanidipine hydrochloride 10 mg/d and felodipine sustained-release tablets 5 mg/d were given to their respective groups. After 6 weeks of treatment, SD of home BP significantly reduced compared with baseline in both groups (P < .05) while SD of home HR also changed significantly after treatment (P < .05). There was no significant difference in SD of home BPV between the lercanidipine and felodipine groups after treatment.

CONCLUSION

Treatment with lercanidipine and felodipine both resulted in reduction of BPV and HRV. There was no significant inter-group difference in reduction of BPV between the groups. Lercanidipine is an effective antihypertensive drug in improving BPV. National clinical trial: NCT01520285.

Does home blood pressure monitoring improve patient outcomes? A systematic review comparing home and ambulatory blood pressure monitoring on blood pressure control and patient outcomes

OBJECTIVE

Our objective was to compare the clinical effectiveness of home blood pressure monitoring (HBPM) and 24-hour ambulatory blood pressure monitoring (ABPM) on blood pressure (BP) control and patient outcomes.

DESIGN

A systematic review was conducted. We also appraised the methodological quality of studies.

DATA SOURCES

PubMed, Scopus, CINAHL, and the Cochrane Central Register of Control Trials (CENTRAL).

INCLUSION CRITERIA

Randomized control trials, prospective and retrospective cohort studies, observational studies, and case-control studies published in English from any year to present that describe HBPM and 24-hour ABPM and report on systolic and/or diastolic BP and/or heart attack, stroke, kidney failure and/or all-cause mortality for adult patients. Due to the nature of the question, studies with only untreated patients were not considered.

RESULTS

Of 1,742 titles and abstractions independently reviewed by two reviewers, 137 studies met predetermined criteria for evaluation. Nineteen studies were identified as relevant and included in the paper. The common themes were that HBPM and ABPM correlated with cardiovascular events and mortality, and targeting HBPM or ABPM resulted in similar outcomes. Associations between BP measurement type and mortality differed by study population. Both the low sensitivity of office blood pressure monitoring (OBPM) to detect optimal BP control by ABPM and the added association of HBPM with cardiovascular mortality supported the routine use of HBPM in clinical practice. There was insufficient data to determine the benefit of using HBPM as a measurement standard for BP control.

CONCLUSION

HBPM encourages patient-centered care and improves BP control and patient outcomes. Given the limited number of studies with both HBPM and ABPM, these measurement types should be incorporated into the design of randomized clinical trials within hypertensive populations.

Home Blood Pressure Monitoring

Hypertension is the most common preventable cause of cardiovascular disease. Home blood pressure monitoring (HBPM) is a self-monitoring tool that can be incorporated into the care for patients with hypertension and is recommended by major guidelines. A growing body of evidence supports the benefits of patient HBPM compared with office-based monitoring: these include improved control of BP, diagnosis of white-coat hypertension and prediction of cardiovascular risk. Furthermore, HBPM is cheaper and easier to perform than 24-hour ambulatory BP monitoring (ABPM). All HBPM devices require validation, however, as inaccurate readings have been found in a high proportion of monitors. New technology features a longer inflatable area within the cuff that wraps all the way round the arm, increasing the 'acceptable range' of placement and thus reducing the impact of cuff placement on reading accuracy, thereby overcoming the limitations of current devices.

Proceedings from Duke resistant hypertension think tank

To identify patients at increased risk for cardiovascular outcomes, apparent treatment resistant hypertension (aTRH) is defined as having a blood pressure (BP) above goal despite the use of ≥3 antihypertensive therapies of different classes at maximally tolerated doses, ideally including a diuretic. In light of growing scientific interest in the treatment of this group, a multistakeholder think tank was convened to discuss the current state of knowledge, improve the care of these patients, and identify appropriate study populations for future observational and randomized trials in the field. Although recent epidemiologic studies in selected populations estimate that the prevalence of aTRH is 10% to 15% of hypertensive patients, further large-scale observational studies will be needed to better elucidate risk factors. To spur the development of therapies for aTRH, the development of an "aTRH" label for pharmacologic and device therapies with a developmental pathway including treatment added to the use of existing therapies is favored. Although demonstration of adequate BP lowering should be sufficient to gain Food and Drug Administration approval for therapies targeting aTRH, assessment of improvement in quality of life and cardiovascular outcomes is also desirable and considered in Centers for Medicare and Medicaid Services coverage decisions. Device trials under the aTRH label will need uniform and consistent processes for defining appropriate patient populations as well as postapproval registries assessing both long-term safety and duration of responses. Finally, patients with aTRH are likely to benefit from evaluation by a hypertension team to assure proper patient identification, diagnostic work-up, and therapeutic management before consideration of advanced or novel therapies to lower BP.

The role of renal denervation in the treatment of hypertension

OPINION STATEMENT

Resistant hypertension remains a difficult clinical disease to treat. It is known to place a patient at higher risk for developing significant cardiovascular, renal, and cerebrovascular disease. There is a current surge in research investigating renal denervation as potential treatment for resistant hypertension, as an overactive renal sympathetic system is known to exert an influence on the underlying pathophysiology. Several small studies have been published, with more underway, evaluating multiple different catheter-based systems that utilize radiofrequency ablation or ultrasound wave energy. These studies are showing promising results, with reduction in office blood pressure for the majority of patients. However, it appears that this does not always translate into definitive real-world observational effects. Variability exists in the number of patients that are able to reduce the amount of medication they take for hypertension, with some requiring an increase in medication. As a result, a more intensive screening process has been proposed, evaluating specific key predictors that may translate into a more favorable clinical response to renal denervation. We recommend that individuals with resistant hypertension continue to be optimized medically, adequately screened for secondary causes of hypertension, and that they consider participation in a renal denervation clinical trial to aid in further advancing the field.

Home blood pressure monitoring in heart transplant recipients: comparison with ambulatory blood pressure monitoring

BACKGROUND

How reliable is home blood pressure monitoring (HBPM) in heart transplant recipients is not known. Possibly, it may underestimate hypertensive burden, because blood pressure (BP) nondipper profile is frequent among these patients. This prospective study has been designed to determine whether HBPM adequately identifies hypertension in heart transplant recipients.

METHOD

We compared HBPM with ambulatory blood pressure monitoring (ABPM) for the diagnosis of uncontrolled hypertension in 74 patients 13.5±6.7 years after heart transplantation. HBPM was measured with a validated semiautomatic device twice every morning and twice every evening on 7 consecutive days, within 15 days of ABPM. We also measured the relationship between HBPM, ABPM, and organ damage as measured by albuminuria and left ventricular mass.

RESULTS

A nondipper profile was found in 53 (72%) patients. HBPM and ABPM were close according to Pearson bivariate correlations. There was no significant correlation between left ventricular mass and BP either at HBPM or ABPM. Proteinuria significantly correlated with systolic BP either at HBPM (R=0.42; P=0.0002) or ABPM (R=0.25; P=0.03). HBPM adequately classified 61 of 74 (82%) patients as hypertensives or as nonhypertensives or controlled hypertensives.

CONCLUSION

Despite a high prevalence of nondipper profile, HBPM gives a reliable estimate of BP burden in most heart transplant recipients. Thus, our results strongly suggest that HBPM is useful for the long-term follow-up of heart transplant recipients.

Lack of impact of a comprehensive intervention on hypertension in the primary care setting

BACKGROUND

The implementation of lifestyle modifications, home blood pressure (BP) measurement, and optimization of antihypertensive drug therapy have been shown to improve BP control in tightly controlled research settings. Our objective was to determine the effect of these interventions in a primary care setting, with the family practitioners and nurses serving as the interventionists.

METHODS

Two hundred twenty hypertensive patients were recruited from 2 health centers that operated in the same building and covered similar populations, with the health centers randomized to function as intervention or control sites. Participants in the intervention group received repeated individual and group counseling from the centrally trained staff of the health center on healthy lifestyles. In addition, their antihypertensive drug therapy was guided by home BP measurements performed at 3-month intervals instead of by conventional office measurements.

RESULTS

After 12 months of follow-up, the between-group differences in the changes of lifestyle variables (body mass index, physical activity, dietary recalls, and urinary sodium/potassium) were nonsignificant. Antihypertensive treatment intensity increased in both groups, but the between-group difference was nonsignificant (P = 0.63). Office systolic/diastolic BP decreased significantly in the intervention (8/6 mm Hg; P < 0.001) and control (11/7 mm Hg; P < 0.001) groups, but the between-group differences were nonsignificant (P = 0.25/0.16).

CONCLUSIONS

Our intervention did not improve BP control as suggested by many prior studies performed in controlled academic settings. This result could be attributed to a lack of motivation and incentives among the staff or because the population was relatively unselected. Greater attention to education and financial incentives might be required in typical primary care settings to obtain better results.

CLINICALTRIALSGOV IDENTIFIER

NCT01915199.

Isolated increases in in-office pressure account for a significant proportion of nurse-derived blood pressure-target organ relations

AIMS

We determined the extent to which relationships between nurse-derived blood pressures (BPs) and cardiovascular damage may be attributed to isolated increases in in-office SBP independent of ambulatory BP.

METHODS

In 750 participants from a community sample, nurse-derived office BP, ambulatory BP, carotid-femoral pulse wave velocity (PWV; applanation tonometry and SphygmoCor software; n=662), and left ventricular mass indexed to height (LVMI; echocardiography; n=463) were determined.

RESULTS

Nurse-derived office BP was associated with organ changes independent of 24-h BP (LVMI; partial r=0.15, P<0.005, PWV; partial r=0.21, P<0.0001) and day BP. However, in both unadjusted (P<0.0001 for both) and multivariate adjusted models (including adjustments for 24-h BP; LVMI; partial r=0.14, P<0.01, PWV; partial r=0.21, P<0.0001), nurse office-day SBP (an index of isolated increases in in-office BP) was associated with target organ changes independent of ambulatory BP and additional confounders, with the highest quartile (≥15 mmHg) showing the most marked increases in LVMI (P<0.0005) and PWV (P<0.0001) as compared to the lowest quartile (<-5 mmHg). These relationships were reproduced in those with normotensive day BP values and the quantitative effect of nurse office-day BP on target organ changes was at least equivalent to that of ambulatory BP.

CONCLUSION

Nurse-elicited isolated increases in in-office BP account for a significant proportion of the relationship between nurse-derived BP and target organ changes independent of ambulatory BP. Therefore, high quality nurse-derived BP measurements do not approximate the impact of BP effects per se on cardiovascular damage.

Home versus ambulatory and office blood pressure in predicting target organ damage in hypertension: a systematic review and meta-analysis

OBJECTIVE

Studies have shown that ambulatory blood pressure (BP) is more closely related to preclinical target organ damage than office measurements. A review and meta-analysis of studies investigating the association of home BP measurements with target organ damage was performed.

METHODS

A PubMed and Cochrane Library search (1950-2011) revealed 23 studies reporting comparative data of home BP versus ambulatory and/or office measurements in terms of their association with several indices of target organ damage. Correlation coefficients were pooled by random-effects model meta-analysis.

RESULTS

Fourteen studies (n = 2485) assessing echocardiographic left ventricular mass index (LVMI) showed similar correlations with home (coefficients r = 0.46/0.28, systolic/diastolic) as with ambulatory BP (0.37/0.26, P = NS for difference versus home BP), and superior to office measurements (r = 0.23/0.19, P < 0.001/0.009 for difference versus home BP). Four methodologically heterogeneous studies assessing the glomerular filtration rate (n = 609) could not be pooled or lead to a concrete result. Four studies assessing carotid intima-media thickness (n = 1222), three assessing pulse wave velocity (n = 720) and two assessing urinary protein excretion (n = 156) showed no difference in pooled correlation coefficients with home versus office BP measurements. With all the measurement methods SBP was more closely associated with target organ damage than DBP.

CONCLUSION

These data suggest that home BP is as good as ambulatory monitoring and superior to office measurements in regard to their association with preclinical organ damage assessed by echocardiographic LVMI. More research is required to evaluate the relationship of home BP with other indices of target organ damage.

A novel approach to office blood pressure measurement: 30-minute office blood pressure vs daytime ambulatory blood pressure

PURPOSE

Current office blood pressure measurement (OBPM) is often not executed according to guidelines and cannot prevent the white-coat effect. Serial, automated, oscillometric OBPM has the potential to overcome both these problems. We therefore developed a 30-minute OBPM method that we compared with daytime ambulatory blood pressure.

METHODS

Patients referred to a primary care diagnostic center for 24-hour ambulatory blood pressure monitoring (ABPM) had their blood pressure measured using the same validated ABPM device for both ABPM and 30-minute OBPMs. During 30-minute OBPM, blood pressure was measured automatically every 5 minutes with the patient sitting alone in a quiet room. The mean 30-minute OBPM (based on t = 5 to t = 30 minutes) was compared with mean daytime ABPM using paired t tests and the approach described by Bland and Altman on method comparison.

RESULTS

We analyzed data from 84 patients (mean age 57 years; 61% female). Systolic and diastolic blood pressures differed from 0 to 2 mm Hg (95% confidence interval, -2 to 2 mm Hg and from 0 to 3 mm Hg) between mean 30-minute OBPM and daytime ABPM, respectively. The limits of agreement were between -19 and 19 mm Hg for systolic and -10 and 13 mm Hg for diastolic blood pressures. Both 30-minute OBPM and daytime ABPM classified normotension, white-coat hypertension, masked hypertension, and sustained hypertension equally.

CONCLUSIONS

The 30-minute OBPM appears to agree well with daytime ABPM and has the potential to detect white-coat and masked hypertension. This finding makes 30-minute OBPM a promising new method to determine blood pressure during diagnosis and follow-up of patients with elevated blood pressures.

Relationship of home blood pressure with target-organ damage in children and adolescents

The objective of this study was to compare home blood pressure (HBP) vs. ambulatory (ABP) and clinic (CBP) measurements in terms of their association with target-organ damage in children and adolescents. A total of 81 children and adolescents (mean age 13 ± 3 years, 53 boys) referred for elevated CBP had measurements of CBP (1 visit), HBP (6 days) and ABP (24-h). Seventy-six participants were also assessed with carotid-femoral pulse wave velocity (PWV) and 54 with echocardiography. Average CBP was 122.1 ± 15.1/71 ± 12.9 mm Hg (systolic/diastolic), HBP 121.3 ± 11.5/69.4 ± 6.6 mm Hg and 24-h ABP 118.9 ± 12/66.6 ± 6.1 mm Hg. Left ventricular mass (LVM) was correlated with systolic blood pressure (BP) (coefficient r = 0.55/0.54/0.45 for 24-h/daytime/nighttime ABP, 0.53 for HBP and 0.41 for CBP; all P< 0.01). No significant correlations were found for diastolic BP. PWV was also significantly correlated with systolic BP (r = 0.52/0.50/0.48 for 24-h/daytime/nighttime ABP, 0.50 for HBP and 0.47 for CBP; all P < 0.01). Only diastolic ABP and HBP were significantly correlated with PWV (r = 0.30 and 0.28, respectively, P<0.05). In multivariate stepwise regression analysis (with age, gender, body mass index [BMI], clinic, home and 24-h ambulatory systolic/diastolic BP and pulse pressure, clinic, home and 24-h heart rate as independent variables), PWV was best predicted by systolic HBP (R(2) = 0.22, beta ± s.e. = 0.06 ± 0.01), whereas LVM was determined (R(2) = 0.67) by 24-h pulse pressure (beta = 1.21 ± 0.41), age (beta = 2.93 ± 1.32), 24-h heart rate (beta = -1.27 ± 0.41) and BMI (beta = 1.78 ± 0.70). These data suggest that, in children and adolescents, ABP as well as HBP measurements appear to be superior to the conventional CBP measurements in predicting the presence of subclinical end-organ damage.

An olmesartan medoxomil-based treatment algorithm is effective in achieving 24-hour BP control in patients with type 2 diabetes mellitus, regardless of age, race, sex, or severity of hypertension: subgroup analysis of the BENIFICIARY study

BACKGROUND

Hypertension often occurs concomitantly with diabetes mellitus, such that >50% of adults with type 2 diabetes have hypertension. These individuals are at a greater risk of developing renal and cardiovascular disease. The currently recommended BP goal of <130/80 mmHg for patients with type 2 diabetes is achieved in only 37.5% of treated patients with diabetes and hypertension.

METHODS

The antihypertensive efficacy of olmesartan medoxomil (OM) ± hydrochlorothiazide (HCTZ) was investigated in prespecified subgroups (age <65/≥65 years, Blacks/non-Blacks, males/females, or stage 1/stage 2 hypertension) of patients with hypertension and type 2 diabetes enrolled in an open-label, single-arm study (n = 192). Patients started treatment with OM 20 mg/day and were uptitrated at 3-week intervals to OM 40, OM/HCTZ 40/12.5, and OM/HCTZ 40/25 mg/day if BP was ≥120/70 mmHg. The primary endpoint was the change in mean 24-hour ambulatory SBP from baseline to week 12, assessed by mean 24-hour ambulatory BP monitoring. Secondary endpoints included changes in mean 24-hour ambulatory DBP, mean daytime ambulatory BP, mean nighttime ambulatory BP, and mean office seated BP, and the proportions of patients achieving prespecified ambulatory BP targets.

SETTING

This was a multicenter study (24 sites) that took place between November 2006 and November 2007 in the US.

RESULTS

BP reductions were significant (p < 0.0001) and similar among subgroups of patients with type 2 diabetes. Following dose titration to OM/HCTZ 40/25 mg/day, similar proportions of patients in the age, race, and sex subgroups (approximately 60-64% across these subgroups) achieved an ambulatory BP target of <130/80 mmHg. A larger proportion of patients with type 2 diabetes and stage 1 hypertension achieved this same goal compared with patients with stage 2 hypertension (75% vs 46.3%). The combination of OM/HCTZ was well tolerated in all patient subgroups irrespective of age, race, sex, or hypertension severity.

CONCLUSIONS

In this open-label study, OM/HCTZ combination therapy was efficacious and well tolerated in subgroups of patients with diabetes and hypertension. [Clinical Trials Registry Number: NCT00403481].

Reproducibility of wrist home blood pressure measurement with position sensor and automatic data storage

Background

Wrist blood pressure (BP) devices have physiological limits with regards to accuracy, therefore they were not preferred for home BP monitoring. However some wrist devices have been successfully validated using etablished validation protocols. Therefore this study assessed the reproducibility of wrist home BP measurement with position sensor and automatic data storage.

Methods

To compare the reproducibility of three different(BP) measurement methods: 1) office BP, 2) home BP (Omron wrist device HEM- 637 IT with position sensor), 3) 24-hour ambulatory BP(24-h ABPM) (ABPM-04, Meditech, Hun)conventional sphygmomanometric office BP was measured on study days 1 and 7, 24-h ABPM on study days 7 and 14 and home BP between study days 1 and 7 and between study days 8 and 14 in 69 hypertensive and 28 normotensive subjects. The correlation coeffcient of each BP measurement method with echocardiographic left ventricular mass index was analyzed. The schedule of home readings was performed according to recently published European Society of Hypertension (ESH)- guidelines.

Results

The reproducibility of home BP measurement analyzed by the standard deviation as well as the squared differeces of mean individual differences between the respective BP measurements was significantly higher than the reproducibility of office BP (p < 0.001 for systolic and diastolic BP) and the reproducibility of 24-h ABPM (p < 0.001 systolic BP, p = 0.127 diastolic BP). The reproducibility of systolic and diastolic office versus 24-h ABPM was not significantly different (p = 0.80 systolic BP, p = 0.1 diastolic BP). The correlation coefficient of 24-h ABMP (r = 0.52) with left ventricular mass index was significantly higher than with office BP (r = 0.31). The difference between 24-h ABPM and home BP (r = 0.46) was not significant.

Conclusion

The short-term reproducibility of home BP measurement with the Omron HEM-637 IT wrist device was superior to the reproducibility of office BP and 24- h ABPM measurement. Furthermore, home BP with the wrist device showed similar correlations to targed organ damage as recently reported for upper arm devices. Although wrist devices have to be used cautious and with defined limitations, the use of validated devices with position sensor according to recently recommended measurement schedules might have the potential to be used for therapy monitoring.

Conventional and 24-h ambulatory blood pressure as independent predictors of elastic arterial properties

OBJECTIVE

No population study investigated whether 24-h ambulatory blood pressure (ABP) predicts distensibility of the elastic common carotid (DCar) and the muscular femoral (DFem) arteries over and beyond conventionally measured blood pressure (CBP).

METHODS

At baseline, we measured CBP and 24-h ABP in 1063 randomly recruited participants (mean age, 44.3 years). CBP was the average of five consecutive readings obtained by trained observers at the participants' homes. We measured arterial distensibility by a wall-tracking ultrasound system, 21 months after CBP and ABP (5-95th percentile interval range, 13-33 months).

RESULTS

Compared with men, women (49.2%) had higher (P<0.03) DCar (24.7 vs. 23.3 x 10(-3)/kPa) and higher DFem (10.6 vs. 9.2 x 10(-3)/kPa). In multivariate-adjusted models, including both CBP and ABP and stratified by sex, DCar was negatively related to systolic, diastolic, and mean arterial CBP in both sexes, and to diastolic ABP in women. DFem was inversely correlated with diastolic ABP in both sexes and with systolic and mean arterial ABP in men. Moreover, DFem was also negatively correlated with systolic and mean arterial CBP in men. In most instances, pulse pressure on CBP or ABP measurement did not predict DCar or DFem. No evidence of influential collinearity between CBP and ABP was observed.

CONCLUSION

Depending on vascular territory, there is competition between highly standardized CBP and ABP in predicting DCar and DFem. These findings show that CBP under standardized conditions, and subject to rigorous quality control, is equally predictive of the elastic properties of large arteries as ABP.

The misdiagnosis of hypertension: the role of patient anxiety

BACKGROUND

The white coat effect (defined as the difference between blood pressure [BP] measurements taken at the physician's office and those taken outside the office) is an important determinant of misdiagnosis of hypertension, but little is known about the mechanisms underlying this phenomenon. We tested the hypothesis that the white coat effect may be a conditioned response as opposed to a manifestation of general anxiety.

METHODS

A total of 238 patients in a hypertension clinic wore ambulatory blood pressure monitors on 3 separate days 1 month apart. At each clinic visit, BP readings were manually triggered in the waiting area and the examination room (in the presence and absence of the physician) and were compared with the mercury sphygmomanometer readings taken by the physician in the examination room. Patients completed trait and state anxiety measures before and after each BP assessment.

RESULTS

A total of 35% of the sample was normotensive, and 9%, 37%, and 19% had white coat, sustained, and masked hypertension, respectively. The diagnostic category was associated with the state anxiety measure (F(3,237) = 6.4, P < .001) but not with the trait anxiety measure. Patients with white coat hypertension had significantly higher state anxiety scores (t = 2.67, P < .01), with the greatest difference reported during the physician measurement. The same pattern was observed for BP changes, which generally paralleled the changes in state anxiety (t = 4.86, P < .002 for systolic BP; t = 3.51, P < .002 for diastolic BP).

CONCLUSIONS

These findings support our hypothesis that the white coat effect is a conditioned response. The BP measurements taken by physicians appear to exacerbate the white coat effect more than other means. This problem could be addressed with uniform use of automated BP devices in office settings.

Call to action on use and reimbursement for home blood pressure monitoring: a joint scientific statement from the American Heart Association, American Society of Hypertension, and Preventive Cardiovascular Nurses Association

Home blood pressure monitoring (HBPM) overcomes many of the limitations of traditional office blood pressure (BP) measurement and is both cheaper and easier to perform than ambulatory BP monitoring. Monitors that use the oscillometric method are currently available that are accurate, reliable, easy to use, and relatively inexpensive. An increasing number of patients are using them regularly to check their BP at home, but although this has been endorsed by national and international guidelines, detailed recommendations for their use have been lacking. There is a rapidly growing literature showing that measurements taken by patients at home are often lower than readings taken in the office and closer to the average BP recorded by 24-hour ambulatory monitors, which is the BP that best predicts cardiovascular risk. Because of the larger numbers of readings that can be taken by HBPM than in the office and the elimination of the white-coat effect (the increase of BP during an office visit), home readings are more reproducible than office readings and show better correlations with measures of target organ damage. In addition, prospective studies that have used multiple home readings to express the true BP have found that home BP predicts risk better than office BP (Class IIa; Level of Evidence A). This call-to-action article makes the following recommendations: (1) It is recommended that HBPM should become a routine component of BP measurement in the majority of patients with known or suspected hypertension; (2) Patients should be advised to purchase oscillometric monitors that measure BP on the upper arm with an appropriate cuff size and that have been shown to be accurate according to standard international protocols. They should be shown how to use them by their healthcare providers; (3) Two to 3 readings should be taken while the subject is resting in the seated position, both in the morning and at night, over a period of 1 week. A total of >/=12 readings are recommended for making clinical decisions; (4) HBPM is indicated in patients with newly diagnosed or suspected hypertension, in whom it may distinguish between white-coat and sustained hypertension. If the results are equivocal, ambulatory BP monitoring may help to establish the diagnosis; (5) In patients with prehypertension, HBPM may be useful for detecting masked hypertension; (6) HBPM is recommended for evaluating the response to any type of antihypertensive treatment and may improve adherence; (7) The target HBPM goal for treatment is <135/85 mm Hg or <130/80 mm Hg in high-risk patients; (8) HBPM is useful in the elderly, in whom both BP variability and the white-coat effect are increased; (9) HBPM is of value in patients with diabetes, in whom tight BP control is of paramount importance; (10) Other populations in whom HBPM may be beneficial include pregnant women, children, and patients with kidney disease; and (11) HBPM has the potential to improve the quality of care while reducing costs and should be reimbursed.

Call to action on use and reimbursement for home blood pressure monitoring: a joint scientific statement from the American Heart Association, American Society Of Hypertension, and Preventive Cardiovascular Nurses Association

Home blood pressure monitoring (HBPM) overcomes many of the limitations of traditional office blood pressure (BP) measurement and is both cheaper and easier to perform than ambulatory BP monitoring. Monitors that use the oscillometric method are currently available that are accurate, reliable, easy to use, and relatively inexpensive. An increasing number of patients are using them regularly to check their BP at home, but although this has been endorsed by national and international guidelines, detailed recommendations for their use have been lacking. There is a rapidly growing literature showing that measurements taken by patients at home are often lower than readings taken in the office and closer to the average BP recorded by 24-hour ambulatory monitors, which is the BP that best predicts cardiovascular risk. Because of the larger numbers of readings that can be taken by HBPM than in the office and the elimination of the white-coat effect (the increase of BP during an office visit), home readings are more reproducible than office readings and show better correlations with measures of target organ damage. In addition, prospective studies that have used multiple home readings to express the true BP have found that home BP predicts risk better than office BP (Class IIa; Level of Evidence A). This call-to-action article makes the following recommendations: (1) It is recommended that HBPM should become a routine component of BP measurement in the majority of patients with known or suspected hypertension; (2) Patients should be advised to purchase oscillometric monitors that measure BP on the upper arm with an appropriate cuff size and that have been shown to be accurate according to standard international protocols. They should be shown how to use them by their healthcare providers; (3) Two to 3 readings should be taken while the subject is resting in the seated position, both in the morning and at night, over a period of 1 week. A total of >or=12 readings are recommended for making clinical decisions; (4) HBPM is indicated in patients with newly diagnosed or suspected hypertension, in whom it may distinguish between white-coat and sustained hypertension. If the results are equivocal, ambulatory BP monitoring may help to establish the diagnosis; (5) In patients with prehypertension, HBPM may be useful for detecting masked hypertension; (6) HBPM is recommended for evaluating the response to any type of antihypertensive treatment and may improve adherence; (7) The target HBPM goal for treatment is <135/85 mm Hg or <130/80 mm Hg in high-risk patients; (8) HBPM is useful in the elderly, in whom both BP variability and the white-coat effect are increased; (9) HBPM is of value in patients with diabetes, in whom tight BP control is of paramount importance; (10) Other populations in whom HBPM may be beneficial include pregnant women, children, and patients with kidney disease; and (11) HBPM has the potential to improve the quality of care while reducing costs and should be reimbursed.

Cost-effectiveness analysis of guidelines for antihypertensive care in Finland

BACKGROUND

Hypertension is one of the major causes of disease burden affecting the Finnish population. Over the last decade, evidence-based care has emerged to complement other approaches to antihypertensive care, often without health economic assessment of its costs and effects. This study looks at the extent to which changes proposed by the 2002 Finnish evidence-based Current Care Guidelines concerning the prevention, diagnosis, and treatment of hypertension (the ACCG scenario) can be considered cost-effective when compared to modelled prior clinical practice (the PCP scenario).

METHODS

A decision analytic model compares the ACCG and PCP scenarios using information synthesised from a set of national registers covering prescription drug reimbursements, morbidity, and mortality with data from two national surveys concerning health and functional capacity. Statistical methods are used to estimate model parameters from Finnish data. We model the potential impact of the different treatment strategies under the ACCG and PCP scenarios, such as lifestyle counselling and drug therapy, for subgroups stratified by age, gender, and blood pressure. The model provides estimates of the differences in major health-related outcomes in the form of life-years and costs as calculated from a 'public health care system' perspective. Cost-effectiveness analysis results are presented for subgroups and for the target population as a whole.

RESULTS

The impact of the use of the ACCG scenario in subgroups (aged 40-80) without concomitant cardiovascular and related diseases is mainly positive. Generally, costs and life-years decrease in unison in the lowest blood pressure group, while in the highest blood pressure group costs and life-years increase together and in the other groups the ACCG scenario is less expensive and produces more life-years. When the costs and effects for subgroups are combined using standard decision analytic aggregation methods, the ACCG scenario is cost-saving and more effective.

CONCLUSION

The ACCG scenario is likely to reduce costs and increase life-years compared to the PCP scenario in many subgroups. If the estimated trade-offs between the subgroups in terms of outcomes and costs are acceptable to decision-makers, then widespread implementation of the ACCG scenario is expected to reduce overall costs and be accompanied by positive outcomes overall.

Factors associated with microalbuminuria in resistant hypertension

Microalbuminuria is a well-known marker for cardiovascular and renal complications. The purpose of our study was to identify factors associated with microalbuminuria in individuals with resistant hypertension. Urine albumin excretion (UAE) was evaluated in 187 patients with resistant hypertension. The association between UAE and clinical, laboratory, and 24-h ABPM variables was investigated through comparison of means, correlation analysis, and logistic regression. A high prevalence of microalbuminuria was found (29.4%-95% CI: 22.9-36.5). In logistic regression, 24-h, HDL-cholesterol, serum creatinine, and diabetes mellitus were independently associated with UAE. Blood pressure control appears to be fundamental for reducing microalbuminuria. Moreover, early identification of individuals with microalbuminuria is of the utmost importance due to its association with cardiovascular and renal damage.

Relative utility of home, ambulatory, and office blood pressures in the prediction of end-organ damage

BACKGROUND

Home blood pressure (HBP) monitoring plays an increasingly important role in the diagnosis and treatment of hypertension. We evaluated the independent value of HBP compared with ambulatory blood pressure (ABP) and office blood pressure (OBP) in the prediction of cardiovascular end-organ damage in normotensive subjects and untreated patients with mild hypertension.

METHODS

One hundred sixty-three subjects underwent measurements of OBP, HBP, ABP, and echocardiography. A physician using a mercury-column sphygmomanometer performed three OBP measurements. The ABP was recorded using a noninvasive ambulatory monitor (mean, 35.4 awake readings per subject). Participants took HBP readings with an automatic, oscillometric device over a 10-week period (mean, 277.9 readings per subject). The left-ventricular mass index (LVMI) was calculated from measurements obtained from two-dimensionally guided M-mode or linear tracings on echocardiography.

RESULTS

For systolic and diastolic blood pressures (SBP/DBP), the correlation coefficients of the LVMI with OBP, awake ABP, and HBP were 0.29/0.27, 0.41/0.26, and 0.47/0.35, respectively (all P < .01). In a multivariate regression analysis in which age, sex, body mass index, OBP, awake ABP, and HBP were included, only age, sex, and HBP were significant predictors of LVMI. When only the first 12 home readings were used, the superiority of HBP was no longer evident.

CONCLUSIONS

In contrast to OBP and ABP, HBP measurements, when averaged over a 10-week period, are independently related to LVMI. The HBP adds prognostic information over and above OBP and ABP in the prediction of cardiovascular end-organ damage, but this relationship appears to depend on the number of readings taken.

Comparison of agreement between clinic and home-measured blood pressure in the Finnish population: the Finn-HOME Study

BACKGROUND

The purpose of this study was to assess the agreement, mean difference, and the detection and control rates of hypertension, between home and clinic blood pressure (BP) measurement in the Finnish population. Variation in home BP during the measurements was also examined.

METHODS

We studied a representative sample of the adult population (2051 45-74-year-old individuals) in Finland. Subjects included in the study underwent a clinical interview and measurement of clinic and home BP. Thresholds for elevated clinic and home BP were 140/90 and 135/85 mmHg.

RESULTS

The mean difference between home and clinic BP, which increased with BP, was 7.7/3.4 mmHg. Overall agreement in diagnosis was only 75.2% (kappa coefficient 0.50). As compared with home BP, clinic BP overestimated the prevalence of hypertension (48.8 versus 42.5%, P < 0.001) and non-significantly underestimated the control of hypertension (28.7 versus 32.8%, P = 0.11). Evening home BP was 4.1/0.4 mmHg higher than morning BP among untreated subjects, but this difference was non-existent or reversed (0.5/-1.4 mmHg) among treated hypertensive individuals. Home BP decreased with an increasing number of measurements.

CONCLUSIONS

The agreement between home and clinic BP in diagnosing hypertension according to the current guidelines is moderate at best, and the difference between home and clinic BP becomes larger at higher levels of BP. Because of the noticeable differences between these two methods, and the better prognostic accuracy of home BP, we endorse the use of home measurements in clinical practice.

Determinación del límite de normalidad de la presión arterial mediante la automedida domiciliaria

OBJECTIVES

Home blood pressure (HBP) is frequently used in clinical evaluation; however the interpretation of the data collected is lacked of a precide definition of normal HBP, so we did this study.

METHODS

A random sample of 1,136 was selected, stratified by gender and age (25 up to 64 years old). Those receiving antihypertensive therapy were excluded. Clinical blood pressure (CBP) consisted of three measurements, with the mercury sphygmomanometer (MS) and with the automatic blood pressure device (Omron 705 CP) (AD). Heart rate (HR), body weight and height were registered. HBP: each participant was asked to obtain 9 home measurements, three in the morning (M), three in the afternoon (A) and three at night (N). Statistical methods included Student's t test for paired comparisons, ANOVA and regression analysis.

RESULTS

CBP and HBP measurements (mmHg) were obtained in 734 participants. The means of S-CBP/D-CBP with the MS were 123.5 +/- 15.1/ 76.4 +/- 10.4 and 122.4 +/- 14.4/75.6 +/- 10.0 and with the AD, 123.4 +/- 16.1/73.7 +/- 10.4. The average of S-HBP/D-HBP in the total sample was 115.0 +/- 14.3/69.2 +/- 9.0. The HBP measurements were significantly lower than CBP (p < 0.05). The mean of clinic HR was 70.3 +/- 10.4. The average of home HR in the whole sample was 67.9 +/- 9.7. The clinic HR and the home HR were significantly different (p < 0.05). The upper limit of normality for HBP obtained from the values that correspond on the mean +2 SD to the CBP value of 140/90 was 135/82. The 95th percentile value of the HBP in the whole sample was 131/80. The upper limit of normality for HBP obtained from the values that correspond on the regression lines in the group with CBP < 140/90 was 125/78, in the group with CBP >or= 140/90 was 130/81 and in the total sample was 128/81.

CONCLUSIONS

We consider that the upper limit of normality of home blood pressure is 130/81. Clinic heart rate is higher than home heart rate, which demonstrates a phenomenon of alerting reaction.