One size does not fit all: universal cuff overestimates oscillometric blood pressure in persons with large arm circumference

OBJECTIVE

Some brachial cuffs for oscillometric blood pressure (BP) measurement are claimed to cover a wide range of upper-arm circumferences; however, their validation is rarely conducted. Our aim was to compare oscillometric BP measurements obtained with a universal cuff with those obtained with an appropriately sized cuff.

METHODS

We utilised the Microlife B6 Connect monitor, conducting oscillometric BP measurements in a random sequence with both a universal cuff (recommended for arm circumferences from 22 to 42 cm) and an appropriately sized cuff (medium for circumference 22-32 cm and large for 32-42 cm). We included 91 individuals with an arm circumference of 22-32 cm and 64 individuals with an arm circumference of 32-42 cm.

RESULTS

For arm circumferences > 32 cm, systolic and diastolic BP measured with the universal cuff was higher than that measured with the large cuff (systolic 6.4 mmHg, 95% confidence interval [CI]). 3.9-8.8, diastolic 2.4 mmHg, 95%CI, 1.2-3.7, p < 0.001 for both). Overestimation of BP with the universal cuff was statistically significant after correcting for the sequence of measurements. No statistical difference was found between the universal cuff and medium cuff for circumferences in the 22-32 cm range. The bladder size in the universal cuff matched the dimensions of the medium-sized cuff; however, the cuff was larger.

CONCLUSION

Overestimation of BP measured with a universal cuff in persons with large arm circumferences is clinically important. It poses the risk of unnecessary initiation or intensification of antihypertensive medication in persons using the universal cuff.

Frequency of office blood pressure measurements and the seasonal variability of blood pressure: results of the Hungarian Hypertension Registry

PURPOSE

Hypertension is a major public health problem, thus, its timely and appropriate diagnosis and management are crucial for reducing cardiovascular morbidity and mortality. The aim of the new Hungarian Hypertension Registry is to evaluate the blood pressure measurement practices of general practitioners (GPs), internists and cardiologists in outpatient clinics, as well as to assess the seasonal variability of blood pressure.

MATERIALS AND METHODS

Omron M3 IT devices were used during four-month periods between October 2018 and April 2023 in GP practices and in hypertension clinics. The blood pressure data were then transmitted online from the monitors' cuffs to a central database using the Medistance system of Omron.

RESULTS

Family physicians (n = 2491), and internists/cardiologists (n = 477) participated in the study. A total of 4804 821 blood pressure measurements were taken during 10 four-month evaluation periods. In the ten periods, the daily average number of measurements was between 3.0 and 5.6. Following ESH diagnostic criteria, the proportion of subjects in optimal, normal and high-normal blood pressure categories were 14, 13.4 and 16.7%, respectively. Altogether 56% of the measurements belonged to stage 1, stage 2 or stage 3 hypertension categories (31.6, 17.1 and 7.4%, respectively). On average, a difference of 5/2 mmHg was observed between winter and summer data in systolic and diastolic blood pressures, respectively. The average systolic blood pressure values were higher in GP practices with more than 2000 patients than in the ones with less than 1500 patients (141.86 mmHg versus 140.02 mmHg, p < 0.05).

CONCLUSION

In conclusion, the low daily average number of blood pressure measurements indicates a limited blood pressure screening awareness/capacity in the case of Hungarian family physicians. In GP practices with more patients, blood pressure is usually less well-controlled. These results suggest that the further promotion of home blood pressure monitoring is necessary.

Evaluating the Effectiveness of a Training on Ergonomic Risks of Measuring Blood Pressure

Background: Musculoskeletal disorders (MSDs) occur as a result of long-term exposure to inappropriate working postures and repetitive use of body postures, leading to harmful consequences for patients, employees, and employers. Evaluating distinct working postures can contribute to effective interventions. Purpose: The aim of this study was to determine ergonomic risks of MSDs during repeated blood pressure measurement processes and to evaluate the effectiveness of a training on this topic. Methods: A pretest/posttest quasi-experimental design studied 64 nurses in a training and research hospital in Turkey. Participants were evaluated for the prevalence and risk of MSDs using the Nordic Musculoskeletal Questionnaire Extended Version and the Rapid Entire Body Assessment (REBA) Checklist, and by photographing them performing the procedure. Nurses with high risk for MSDs received an ergonomics training program and were followed up twice in 3 months. Results: Reduction in prevalence of MSDs in neck, shoulder, and hip/thigh areas, and in mean REBA scores after the training were statistically significant. Conclusion: Nurses should be trained about correct posture for specific high-risk activities that may cause MSDs, and offered exercise programs that support the musculoskeletal system.

Ability of a 24-h ambulatory cuffless blood pressure monitoring device to track blood pressure changes in clinical practice

OBJECTIVE

There is an increasing number of cuffless blood pressure (BP) measurement (BPM) devices. Despite promising results when comparing single measurements, the ability of these devices to track changes in BP levels over 24 h related to an initial calibration BP (CalibBP) is unknown. Our aim was to analyse this ability in a cuffless device using pulse transit time.

METHODS

We prospectively enrolled 166 participants for simultaneously performed cuffless (Somnotouch-NIBP) and cuff-based (Spacelabs 90217A/IEM Mobil-O-graph) 24 h BPM. As CalibBP for the cuffless device, first cuff-based BP was used. As surrogate for changes in BP levels after the CalibBP, we used the difference between the CalibBP and mean 24 h, awake and asleep BP measured by the two devices. In addition, we analysed the relationship between the difference of the CalibBP and the cuff-based BPM versus the difference between the cuff-based and the cuffless BPM devices.

RESULTS

Mean(SD) difference between the CalibBP and mean 24hBP by the cuff-based or cuffless BP device were 7.4 (13.2) versus 1.8 (8.3) mmHg for systolic ( P  < 0.0001) and 6.6 (6.8) versus 1.6 (5.8) mmHg for diastolic ( P  < 0.0001). A near linear relationship was seen among the difference between the CalibBP and the cuff-based BPM values and the difference between the cuff-based and cuffless BPM device.

CONCLUSION

Our data indicate a lower ability of the cuffless BPM device to track changes of BP levels after CalibBP. In addition, cuffless device accuracy was associated with the changes in BP levels after the initial CalibBP - the larger the BP level change, the larger the difference between the devices.

REGISTRATION

https://www.clinicaltrials.gov ; Unique identifier: NCT03054688; NCT03975582.

Performance of the Aktiia optical blood pressure measurement device in the elderly: a comparison with double blinded auscultation in different body positions

BACKGROUND

Accurate blood pressure (BP) measurement is essential for the correct diagnosis and management of hypertension (HTN) especially in the elderly population. As with of all BP devices, the accuracy of cuffless devices must be verified. This study (NCT04027777) aimed to evaluate the performance of a wrist cuffless optical BP device in an elderly population cohort in different body positions with auscultation as the reference measurement.

DESIGN AND METHODS

Patients aged 65-85 years with different BP categories but without diabetes were recruited. After an initial calibration based on auscultatory measurements, BP estimation from the Aktiia Bracelet (Aktiia SA, Switzerland) were compared to reference double-blinded auscultatory measurements in sitting, standing and lying positions on four separate visits distributed over one month. In the absence of a universal standard for cuffless BP device at the time of the study, modified ISO81060-2 criteria were used for performance analysis.

RESULTS

Thirty-five participants were included in the analysis fulfilling the inclusion requirements of ISO 81060-2. A total of 469 paired measurements were obtained with overall 83% acceptance rate. Differences (mean ± SD)   between Aktiia Bracelet and auscultation for systolic BP were -0.26 ± 9.96 mmHg for all body positions aggregated (sitting 1.23 ± 7.88 mmHg, standing -1.81 ± 11.11 mmHg, lying -1.8 ± 9.96 mmHg). Similarly, differences for diastolic BP were -0.75 ± 7.0 mmHg (0.2 ± 5.55 mmHg, -5.35 ± 7.75 mmHg and -0.94 ± 7.47 mmHg, respectively). Standard deviation of the averaged differences per subject for systolic/diastolic BP was 3.8/2.5 mmHg in sitting and 4.4/3.7 mmHg for all body positions aggregated.

CONCLUSIONS

Overall, this study demonstrates a similar performance of the Aktiia Bracelet compared to auscultation in an elderly population in body positions representative of daily activities. The use of more comfortable, non-invasive, and non-occlusive BP monitors during long periods may facilitate e-health and may contribute to better management of HTN, including diagnosis and treatment of HTN, in the elderly.

Practical Application of a New Cuffless Blood Pressure Measurement Method

It would be useful to develop a reliable method for the cuffless measurement of blood pressure (BP), as such a method could be made available anytime and anywhere for the effective screening and monitoring of arterial hypertension. The purpose of this study is to evaluate blood pressure measurements through a CardioQVARK device in clinical practice in different patient groups.

METHODS

This study involved 167 patients aged 31 to 88 years (mean 64.2 ± 7.8 years) with normal blood pressure, high blood pressure, and compensated high blood pressure. During each session, three routine blood pressure measurements with intervals of 30 s were taken using a sphygmomanometer with an appropriate cuff size, and the mean value was selected for comparison. The measurements were carried out by two observers trained at the same time with a reference sphygmomanometer using a Y-shaped connector. In the minute following the last cuff-based measurements, an electrocardiogram (ECG) with an I-lead and a photoplethysmocardiogram were recorded simultaneously for 3 min with the CardioQVARK device. We compared the systolic and diastolic BP obtained from a cuff-based mercury sphygmomanometer and smartphone-case-based BP device: the CardioQVARK monitor. A statistical analysis plan was developed using the IEEE Standard for Wearable Cuffless Blood Pressure Devices. Bland-Altman plots were used to estimate the precision of cuffless measurements.

RESULTS

The mean difference between the values defined by CardioQVARK and the cuff-based sphygmomanometer for systolic blood pressure (SBP) was 0.31 ± 3.61, while that for diastolic blood pressure (DBP) was 0.44 ± 3.76. The mean absolute difference (MAD) for SBP was 3.44 ± 2.5 mm Hg, and that for DBP was 3.21 ± 2.82 mm Hg. In the subgroups, the smallest error (less than 3 mm Hg) was observed in the prehypertension group, with a slightly larger error (up to 4 mm Hg) found among patients with a normal blood pressure and stage 1 hypertension. The largest error was found in the stage 2 hypertension group (4-5.5 mm Hg). The largest error was 4.2 mm Hg in the high blood pressure group. We, therefore, did not record an error in excess of 7 mmHg, the upper boundary considered acceptable in the IEEE recommendations. We also did not reach a mean error of 5 mmHg, the upper boundary considered acceptable according to the very recent ESH recommendations. At the same time, in all groups of patients, the systolic blood pressure was determined with an error of less than 5 mm Hg in more than 80% of patients. While this study shows that the CardioQVARK device meets the standards of IEEE, the Bland-Altman analysis indicates that the cuffless measurement of diastolic blood pressure has significant bias. The difference was very small and unlikely to be of clinical relevance for the individual patient, but it may well have epidemiological relevance on a population level. Therefore, the CardioQVARK device, while being worthwhile for monitoring patients over time, may not be suitable for screening purposes. Cuffless blood pressure measurement devices are emerging as a convenient and tolerable alternative to cuff-based devices. However, there are several limitations to cuffless blood pressure measurement devices that should be considered. For instance, this study showed a high proportion of measurements with a measurement error of <5 mmHg, while detecting a small, although statistically significant, bias in the measurement of diastolic blood pressure. This suggests that this device may not be suitable for screening purposes. However, its value for monitoring BP over time is confirmed. Furthermore, and most importantly, the easy measurement method and the device portability (integrated in a smartphone) may increase the self-awareness of hypertensive patients and, potentially, lead to an improved adherence to their treatment.

CONCLUSION

The cuffless blood pressure technology developed in this study was tested in accordance with the IEEE protocol and showed great precision in patient groups with different blood pressure ranges. This approach, therefore, has the potential to be applied in clinical practice.

History of blood pressure measurement in newborns and infants

The development of methods for measuring blood pressure (BP) in newborns and small children has a rich history. Methods for BP measuring in adults had to be adapted to this age group. For measuring BP in direct invasive way, a suitable approach had to be found to access the arterial circulation through the umbilical and later radialis artery. Currently, results obtained from direct invasive BP measurement are considered the "gold standard". The development of non-invasive methods for BP measuring in newborns and children began with the use of von Basch's sphygmomanometer (1880). In 1899, Gustav Gärtner constructed the device, which was the basis for the flush method. After the discovery of the palpation and auscultation methods, these methods were also used for BP measurement in newborns and children, however, the BP values obtained in these ways were typically underestimated using excessively wide cuffs. From the auscultation method, methods utilizing ultrasound and infrasound to detect arterial wall movement and blood flow were later developed. The oscillometric method for BP measurement was introduced by E. J. Marey so early as in 1876. In 1912, P. Balard used the oscillometric technique to measure blood pressure in a large group of newborns. Through different types of oscillometers using various methods for detecting vascular oscillations (such as xylol method, impedance and volume plethysmography, etc.), the development has continued to assessment of vascular oscillations by modern sensor technology and software. For continuous non-invasive blood pressure measurement, the volume-clamp method, first described by Jan Peňáz in 1968, was developed. After modification for use in newborns, application of the cuff to the wrist instead of the finger, it is primarily used in clinical physiological studies to evaluate beat-to-beat BP and heart rate pressure variability, such as in the determination of the baroreflex sensitivity.

The effect of oscillometric blood pressure measurement on pain response in preterm infants

AIM

Preterm neonates are exposed to many painful procedures in neonatal intensive care units. This study aims to evaluate the effect of oscillometric blood pressure (BP) measurement on pain response in preterm infants.

METHODS

This prospective study was performed over 4 months in a level III neonatal intensive care unit. Premature neonates whose gestational age was <34 weeks and postmenstrual age <36 weeks were included if they had no systemic diseases. BP measurement was performed on the right arm. The Premature Infant Pain Profile-Revised (PIPP-R) scores were evaluated three times before, during, and 10 min after BP measurement.

RESULTS

During the 5-month period, 100 preterm neonates (53 male infants) were included in the study. Median birth weight and gestational age of the infants were 1148 (IQR: 1015-1300) g and 28 (IQR: 27-30) weeks, respectively. PIPP-R scores were found to be ≥7 in 34% of neonates. PIPP-R scores increased during BP measurement and decreased after.

CONCLUSION

Our results demonstrated that oscillometric BP measurement which is generally accepted as a non-invasive tool for monitoring can produce mild pain in premature neonates of postmenstrual age <36 weeks.

Health Monitoring via Heart, Breath, and Korotkoff Sounds by Wearable Piezoelectret Patches

Real-time monitoring of vital sounds from cardiovascular and respiratory systems via wearable devices together with modern data analysis schemes have the potential to reveal a variety of health conditions. Here, a flexible piezoelectret sensing system is developed to examine audio physiological signals in an unobtrusive manner, including heart, Korotkoff, and breath sounds. A customized electromagnetic shielding structure is designed for precision and high-fidelity measurements and several unique physiological sound patterns related to clinical applications are collected and analyzed. At the left chest location for the heart sounds, the S1 and S2 segments related to cardiac systole and diastole conditions, respectively, are successfully extracted and analyzed with good consistency from those of a commercial medical device. At the upper arm location, recorded Korotkoff sounds are used to characterize the systolic and diastolic blood pressure without a doctor or prior calibration. An Omron blood pressure monitor is used to validate these results. The breath sound detections from the lung/ trachea region are achieved a signal-to-noise ration comparable to those of a medical recorder, BIOPAC, with pattern classification capabilities for the diagnosis of viable respiratory diseases. Finally, a 6×6 sensor array is used to record heart sounds at different locations of the chest area simultaneously, including the Aortic, Pulmonic, Erb's point, Tricuspid, and Mitral regions in the form of mixed data resulting from the physiological activities of four heart valves. These signals are then separated by the independent component analysis algorithm and individual heart sound components from specific heart valves can reveal their instantaneous behaviors for the accurate diagnosis of heart diseases. The combination of these demonstrations illustrate a new class of wearable healthcare detection system for potentially advanced diagnostic schemes.

Validation of the JOYTECH DBP-6279B blood pressure monitor in adults and adolescents according to the AAMI/ESH/ISO universal standard(ISO 81060-2:2018 + Amd.1:2020)

This study aimed to validate the accuracy of DBP-6279B, an automated inflationary oscillometric upper-arm blood pressure (BP) monitor, in the sitting position according to the AAMI/ESH/ISO (81060-2 : 2018 + Amd.1 : 2020) universal standard protocol. SBPs and DBPs were measured simultaneously on the same arm in 88 adults (female : male = 47 : 41) with a mean age of 56.85 years using a mercury sphygmomanometer (two observers) and a DBP-6279B device (one supervisor). The AAMI/ESH/ISO 81060-2 : 2018 and Amd.1 : 2020 universal standards for the validation of BP-measuring devices in adults and adolescents were followed. A total of 259 valid pairs of data were used in the analysis. According to Criterion 1, the mean difference of SBP between the test device (DBP-6279B) and the reference device (the mercury sphygmomanometer) was 0.75 mmHg, with a SD of 7.66 mmHg. The mean difference in DBP was 1.13 mmHg, with a SD of 6.14 mmHg. The mean difference of both SBP and DBP was less than 5 mmHg, and the SD was less than 8 mmHg, which met the requirements. According to Criterion 2, the mean difference of SBP between the test device and the reference device was 0.85 mmHg, and the SD was 6.56 mmHg, which was less than 6.88 mmHg and met the requirements. The mean difference in DBP was 1.27 mmHg, and the SD was 5.42 mmHg, which was less than 6.82 mmHg and met the requirements. DBP-6279B fulfilled the requirements of the AAMI/ESH/ISO universal standard (ISO 81060-2 : 2018 + Amd.1 : 2020); hence, it can be recommended for both clinical and self/home BP measurement in adults and adolescents.

A randomized n-of-1 study comparing blood pressure measured on a clothed arm and on an arm with a rolled-up sleeve

BACKGROUND

Blood pressure [BP] should be measured using a bare upper arm with an appropriately sized cuff. In practice, it is more convenient to measure BP on a bare arm below a rolled-up sleeve or on a sleeved arm.

AIM

A n-of-1 randomized controlled trial was performed to assess the difference between BP measurements over a sleeve or below a rolled-up sleeve.

METHODS

The study subject was male, white, 72 years old, BMI 26 kg/m2, arm circumference 29 cm, and under stable antihypertensive treatment. The mean of three BP measurements over a thin sleeve was compared with measurements below a rolled-up sleeve. Additional measurements on a completely bare arm, with thicker sleeves and up to three layers were performed. The order of measurements was determined by chance and two oscillometric devices were used. Descriptive statistics, Bland-Altman test and 2-side T test were used for comparisons.

RESULTS

504 measurements were performed: 50 % over the sleeve and 50 % below the rolled-up sleeve. The mean systolic blood pressure (SBP) was respectively 116.9 ± 9. 2 [95% CI 115.7-118.0, range 96-135] and 122.8 ± 9.2 [95% CI 121.7-124.0, range 103-139, p = 0.001] mm Hg. The mean diastolic blood pressure [DBP] was respectively 67.6 ± 6.8 [95% CI 66.8-68.4, range 52-84] and 71.8 ± 6.8 [95% CI 71.0-72.7, range 55-85, p = 0.001] mm Hg. There was no significant difference between the measurements over the sleeve and on the completely bare arm [n = 94, p = 0.97]. Sleeve thickness with 2 layers up to 3 mm thick did not affect the results.

CONCLUSIONS

Blood pressure measurements over a thin sleeve were significantly lower than measurements below a rolled-up sleeve and match measurements on a completely bare arm.

B3X: a novel efficient algorithm for accurate automated auscultatory blood pressure estimation

Objective.The auscultatory technique is still considered the most accurate method for non-invasive blood pressure (NIBP) measurement, although its reliability depends on operator's skills. Various methods for automated Korotkoff sounds analysis have been proposed for reliable estimation of systolic (SBP) and diastolic (DBP) blood pressures. To this aim, very complex methodologies have been presented, including some based on artificial intelligence (AI). This study proposes a relatively simple methodology, named B3X, to estimate SBP and DBP by processing Korotkoff sounds recordings acquired during an auscultatory NIBP measurement.Approach.The beat-by-beat change in morphology of adjacent Korotkoff sounds is evaluated via their cross-correlation. The time series of the beat-by-beat cross-correlation and its first derivative are analyzed to locate the timings of SBP and DBP values. Extensive tests were performed on a public database of 350 annotated measurements, and the performance was evaluated according to the BHS, AAMI/ANSI, and International Organization for Standardization (ISO) quality standards.Main results.The proposed approach achieved 'A' scores for SBP and DBP in the BHS grading system, and passed the quality tests of AAMI/ANSI and ISO standards. The B3X algorithm outperformed two well-established algorithms for oscillometric NIBP measurement in both SBP and DBP estimation. It also outperformed four AI-based algorithms in DBP estimation, while providing comparable performance for SBP, at the cost of a much lower computational burden. The full code of the B3X algorithm is provided in a public repository.Significance.The very good performances ensured by the proposed B3X algorithm, at a low computational cost and without the need for parameter training, support its direct implementation into clinical blood pressure (BP) monitoring devices. The results of this study pave the way for solving/overcoming the trade-off between the accuracy of the auscultatory technique and the objectivity of oscillatory measurements, by bringing an automated auscultatory BP measurement method in clinical practice.

Automatic Calibration of a Device for Blood Pressure Waveform Measurement

This article presents a prototype of a new, non-invasive, cuffless, self-calibrating blood pressure measuring device equipped with a pneumatic pressure sensor. The developed sensor has a double function: it measures the waveform of blood pressure and calibrates the device. The device was used to conduct proof-of-concept measurements on 10 volunteers. The main novelty of the device is the pneumatic pressure sensor, which works on the principle of a pneumatic nozzle flapper amplifier with negative feedback. The developed device does not require a cuff and can be used on arteries where cuff placement would be impossible (e.g., on the carotid artery). The obtained results showed that the systolic and diastolic pressure measurement errors of the proposed device did not exceed ±6.6% and ±8.1%, respectively.

Technical evaluation of a simulator for accurate reproduction of oscillometric blood pressure pulses, providing traceability for automated oscillometric sphygmomanometers

Oscillometric blood pressure measurement devices are not directly traceable to primary standards. Currently, device accuracy is measured by comparison between a sample device and reference measurements in a clinical trial. We researched in this study the potential for an alternative evaluation with a simulator. Our research simulator was studied for repeatability and accuracy in delivering simulated blood pressure pulses. Clinical cuff pressure measurements were obtained, along with simultaneous recordings of oscillometric pulse waveforms, spanning the clinical range of cuff pressures, pulse intervals and pulse shapes. Oscillometric pulse peak amplitudes ranged from 1.1 to 3.6 mmHg. Simulated repeatability results showed an average Standard Deviation (SD) for pulse peaks of 0.018 mmHg; 1.0% of peak amplitudes. Comparing simulated pulse shapes, the average repeat SD was 0.015 mmHg; 0.8% of the normalised pulse shapes. The simulated accuracy results had a mean error of - 0.014 ± 0.042 mmHg with a mean accuracy of 97.8%. For pulse shape the corresponding values were - 0.104 ± 0.071 mmHg with a mean accuracy of 95.4%. The correlation between the reference and simulated pulse shapes ranged from 0.991 to 0.996 (all p < 0.00003), with a mean 0.994. We conclude that oscillometric pulses can be reproduced with high repeatability and high accuracy with our research simulator. The extended uncertaintyU(psim) = 0.3 mmHg for the simulated pulses is dominated by the uncertainty (64%) of the clinical reference data. These results underpin the potential of the simulator to become a secondary standard for millions of oscillometric sphygmomanometers.

Advances in the Pathogenesis and Treatment of Resistant Hypertension

Hypertension is a prevalent chronic disease associated with an increased risk of cardiovascular (CV) premature death, and its severe form manifests as resistant hypertension (RH). The accurate prevalence of resistant hypertension is difficult to determine due to the discrepancy in data from various populations, but according to recent publications, it ranges from 6% to 18% in hypertensive patients. However, a comprehensive understanding of the pathogenesis and treatment of RH is essential. This review emphasizes the importance of identifying the causes of treatment resistance in antihypertensive therapy and highlights the utilization of appropriate diagnostic methods. We discussed innovative therapies such as autonomic neuromodulation techniques like renal denervation (RDN) and carotid baroreceptor stimulation, along with invasive interventions such as arteriovenous anastomosis as potential approaches to support patients with inadequate medical treatment and enhance outcomes in RH.

[The new recommendations for hypertension therapy]

The new guidelines of the European Society of Hypertension (ESH) are a milestone for the improved care of patients with hypertension. The aim was to provide a comprehensive guide and a detailed description of uncomplicated but also complicated hypertension with its comorbidities for everyday practice. Numerous new aspects were added, and clinical situations were also described and recommendations for action were given. The most important general aspects of practical high-pressure diagnostics, prognosis assessment, and basic treatment with the blood pressure goals, as well as follow-up care are presented in the overview.

Prevalence of persistent hypertension and situational hypertension in a population of elderly cats in The Netherlands

OBJECTIVES

Systemic arterial hypertension is increasingly recognised and can have serious adverse consequences in cats. Unfortunately, the act of measuring blood pressure itself may cause an increase in blood pressure, known as situational hypertension. It is currently unknown how often this phenomenon occurs. The aim of this study was to evaluate the prevalence of persistent hypertension and situational hypertension in an elderly population of cats in a first-opinion clinic and to assess which factors were associated with systolic hypertension.

METHODS

In this prospective study, systolic blood pressure was measured in 185 cats aged ⩾10 years using the Doppler sphygmomanometry method according to the recommendations of the American College of Veterinary Internal Medicine consensus statement. Age, sex, body weight, body condition score, position during blood pressure measurement and apparent stress level were assessed. If a systolic blood pressure >160 mmHg was found, measurements were repeated to evaluate if persistent hypertension or situational hypertension was present. The first set of blood pressure measurements were used for all the statistical analyses.

RESULTS

The median systolic blood pressure for this population was 140 mmHg. The prevalence of persistent hypertension was at least 14.6% and situational hypertension at least 5.4%. Factors significantly associated with hypertension were age, higher apparent stress levels and a sitting position during measurement. Sex, body weight or body condition score did not significantly influence systolic blood pressure.

CONCLUSIONS AND RELEVANCE

Both persistent hypertension and situational hypertension are common in elderly cats. There are no reliable parameters to distinguish between the two, underlining the importance of a standard protocol and repeating measurements during a follow-up visit when hypertension is found. Age, demeanour and body position during blood pressure measurement influenced blood pressure in this population of elderly cats.

Non-invasive central aortic pressure measurement: what limits its application in clinical practice?

The following article highlights the need for methodological transparency and consensus for an accurate and non-invasive assessment of central aortic blood pressure (aoBP), which would contribute to increasing its validity and value in both clinical and physiological research settings. The recording method and site, the mathematical model used to quantify aoBP, and mainly the method applied to calibrate pulse waveforms are essential when estimating aoBP and should be considered when analyzing and/or comparing data from different works, populations and/or obtained with different approaches. Up to now, many questions remain concerning the incremental predictive ability of aoBP over peripheral blood pressure and the possible role of aoBP-guided therapy in everyday practice. In this article, we focus on "putting it on the table" and discussing the main aspects analyzed in the literature as potential determinants of the lack of consensus on the non-invasive measurement of aoBP.

Comparison of Blood Pressure Measurements from Clinical Practice and a Research Study At Kaiser Permanente Southern California

BACKGROUND

Accurate blood pressure (BP) measurement is essential to identify and manage hypertension. Prior studies have reported a difference between BP measured in routine patient care and in research studies. We aimed to investigate the agreement between BP measured in routine care and research-grade BP in Kaiser Permanente Southern California, a large, integrated healthcare system with initiatives to standardize BP measurements during routine patient care visits.

METHODS

We included adults ≥65 years old with hypertension, taking antihypertensive medication, and participating in the Ambulatory Blood Pressure in Older Adults (AMBROSIA) study in 2019-2021. Clinic BP from routine care visits was extracted from the electronic health record. Research-grade BP was obtained by trained AMBROSIA study staff via an automatic oscillometric device. The mean difference between routine care and research-grade BP, limits of agreement, and correlation were assessed.

RESULTS

We included 309 participants (mean age 75 years; 54% female; 49% non-Hispanic white). Compared with measurements from routine care, mean research-grade systolic BP (SBP) was 0.1 mm Hg higher (95% CI: -1.5 to 1.8) and diastolic BP (DBP) was 0.4 mm Hg lower (95% CI: -1.6 to 0.7). Limits of agreement were -29 to 30 mm Hg for SBP and -21 to 20 mm Hg for DBP. The intraclass correlation coefficient was 0.42 (95% CI: 0.33 to 0.51) for SBP and 0.43 (95% CI: 0.34 to 0.52) for DBP.

CONCLUSIONS

High within-person variation and moderate correlation were present between BP measured in routine care and following a research protocol suggesting the importance of standardized measurements.

Automatic non-invasive blood pressure measurement in left ventricular assist device patients with a photoplethysmography assisted device

INTRODUCTION

Non-invasive measurement of blood pressure in patients with a left ventricular assist device (LVAD) is challenging due to the mechanical properties of these circulatory support devices. Keeping blood pressure in a target range is crucial to reduce the risk of LVAD complications. As current assessment methods require trained personnel resulting in infrequent monitoring, devices for home-based measurements are sorely needed.

OBJECTIVES

In this paper, we report a measurement method and a custom-made monitoring device based on photoplethysmography (PPG) enabling automated measurement of the mean arterial pressure (MAP) of patients with LVAD.

METHODS

The method and the device were tested on 21 adult patients with LVAD, and the estimated MAP values were compared to MAP values measured simultaneously by a human expert applying the commonly used Doppler-based method.

RESULTS

Results of the proposed method showed highly significant correlation with Doppler-based MAP values (R = 0.85 for inflation, p < 0.001; R = 0.96 for deflation, p<0.001). The mean difference of the proposed method to the Doppler-based MAP values was 1.48 ± 5.43 mmHg for inflation and -0.19 ± 2.71 mmHg for deflation.

CONCLUSION

The results demonstrate that the proposed method is a promising direction to achieve accurate, automated, non-invasive BP measurement, applicable in home health monitoring for patients with LVAD.

A novel professional automated auscultatory blood pressure monitor with visual display of Korotkoff sounds: InBody BPBIO480KV validation according to the Association for the Advancement of Medical Instrumentation/European Society of Hypertension/International Organization for Standardization Universal Standard

OBJECTIVE

A novel automated auscultatory upper arm-cuff blood pressure (BP) monitor (InBody BPBIO480KV) for office use was developed. An electronic stethoscope embedded in the device cuff records the Korotkoff sounds, which are audible to the user and graphically displayed during cuff deflation. Automated BP measurements are provided, while allowing the user to assess the Korotkoff sounds. The device accuracy was tested using the Association for the Advancement of Medical Instrumentation/European Society of Hypertension/International Organization for Standardization (AAMI/ESH/ISO) Universal Standard (ISO 81060-2:2018) and its Amendment 1.2020-01.

METHODS

Participants were recruited to fulfil the age, sex, BP, arm circumference and cuff distribution criteria of the Universal Standard in general population using the same arm sequential measurement method. Three cuffs of the test device were used for arm circumference 23-28, 28-35 and 33-42 cm.

RESULTS

Data from 85 individuals were analysed [mean age 57.3 ± 15.0 (SD) years, 53 men, arm circumference 23-42 cm]. For validation criterion 1, the mean ± SD of the differences between the test device and reference BP readings ( N  = 255) was 0.3 ± 5.5/0.6 ± 4.7 mmHg (systolic/diastolic; threshold ≤5 ± 8 mmHg). For criterion 2, the SD of the averaged BP differences per individual ( N  = 85) was 3.76/3.61 mmHg (systolic/diastolic; threshold ≤6.95/6.91 mmHg).

CONCLUSION

The InBody BPBIO480KV device for office use, which provides automated auscultatory measurements while reproducing and displaying the Korotkoff sounds, comfortably fulfilled the AAMI/ESH/ISO Universal Standard requirements in general population and can be recommended for clinical use. The assessment of Korotkoff sounds by healthcare professionals for evaluating the quality of automated measurements requires further evaluation.

Most Recent Trials and Advances in Hypertension

Hypertension is one of the most prevalent cardiovascular risk factors and blood pressure control remains a clinical challenge, especially for patients with established cardiovascular disease. Late-breaking clinical trials and other evidence in hypertension have evolved to assess the most accurate ways to measure blood pressure, the use of combination therapies, considerations in special populations and evaluation of new techniques. Recent evidence supports the superiority of ambulatory or 24-hour blood pressure measurements, rather than office blood pressure measurements, for the assessment of cardiovascular risk. The use of fixed-dose combinations and polypills has been demonstrated to be valid and to provide clinical benefits beyond blood pressure control. There have also been advances in new approaches such as telemedicine, devices and the use of algorithms. Clinical trials have provided valuable data on blood pressure control in primary prevention, during pregnancy and in the elderly. The role of renal denervation remains unsolved but innovative techniques using ultrasound or alcohol injections are being explored. Current evidence and results of latest trials are summarised in this review.

Changes of oscillogram envelope maximum with blood pressure and aging: a quantitative observation

Objective.The oscillometric blood pressure (BP) measurement technique estimates BPs from analyzing the oscillometric cuff pressure waveform (oscillogram) envelope. The oscillogram envelope maximum is associated with physiological changes and influences BP measurement accuracy. We aim to quantitatively investigate the effect of BP and aging on the changes of oscillogram envelope maximum.Approach.Four hundred and sixty-two subjects (214 female, 248 male) were recruited. The cuff pressure was digitally recorded during linear cuff deflation to derive oscillogram envelopes and their maximums. Moderation analysis was performed to investigate whether the relationship between BP and envelope maximum was moderated by age. Subjects were divided into five age categories and three BP groups. The envelope maximums were compared between different BP and age categories to qualify their changes with increased BP and aging.Main results.Age has a significant moderating effect on the relationship between BP and envelope maximum (P < 0.05). The oscillogram envelope maximums increased significantly with increased BPs (P < 0.05 between each BP groups) and aging (P < 0.05 for > 60 years old groups in comparison with younger groups).Significance.This study experientially and theoretically concluded the BPs and aging are two important factors that influence the maximum value of the oscillogram envelope.

Unattended versus Attended Blood Pressure Measurement: Relationship with Retinal Microcirculation

Though the relationship between both “attended” and “unattended” BP and several forms of target organ damage have been evaluated, data on retinal arteriolar alterations are lacking. The aim of our study was to evaluate the relationship between “attended” or “unattended” BP values and retinal arteriolar changes in consecutive individuals undergoing a clinical evaluation and assessment of retinal fundus at an ESH Excellence Centre. An oscillometric device programmed to perform 3 BP measurements, at 1 min intervals and after 5 min of rest was used on all individuals to measure BP with the patient alone in the room (“unattended”) or in the presence of the physician (“attended”) in the same day in a random order. The retinal arteriole’s wall thickness (WT) was measured automatically by a localization algorithm as the difference between external (ED) and internal diameter (ID) by adaptive optics (RTX-1, Imagine Eyes, Orsay, Francia). Media-to-lumen ratio (WLR) of the retinal arterioles and cross-sectional area (WCSA) of the vascular wall were calculated. Results: One-hundred-forty-two patients were examined (mean age 57 ± 12 yrs, 48% female, mean BMI 26 ± 4). Among them, 60% had hypertension (84% treated) and 11% had type 2 diabetes mellitus. Unattended systolic BP (SBP) was lower as compared to attended SBP (129 ± 14.8. vs. 122.1 ± 13.6 mmHg, p < 0.0001). WLR was similarly correlated with unattended and attended SBP (r = 0.281, p < 0.0001 and r = 0.382, p < 0.0001) and with unattended and attended diastolic BP (r = 0.34, p < 0.001 and r = 0.29, p < 0.0001). The differences between correlations were not statistically significant (Steiger’s Z test). Conclusion: The measurement of “unattended” or “attended” BP provides different values, and unattended BP is lower as compared to attended BP. In this study a similar correlation was observed between attended and unattended BP values and structural changes of retinal arterioles.

Higher Arm Versus Lower Arm Systolic Blood Pressure and Cardiovascular Outcomes: a Meta-Analysis of Individual Participant Data From the INTERPRESS-IPD Collaboration

Guidelines recommend measuring blood pressure (BP) in both arms, adopting the higher arm readings for diagnosis and management. Data to support this recommendation are lacking. We evaluated associations of higher and lower arm systolic BPs with diagnostic and treatment thresholds, and prognosis in hypertension, using data from the Inter-arm Blood Pressure Difference—Individual Participant Data Collaboration.

Predicting Out-of-Office Blood Pressure in a Diverse US Population

BACKGROUND

The PRedicting Out-of-OFfice Blood Pressure (PROOF-BP) algorithm accurately predicted out-of-office blood pressure (BP) among adults with suspected high BP in the United Kingdom and Canada. We tested the accuracy of PROOF-BP in a diverse US population and evaluated a newly developed US-specific algorithm (PROOF-BP-US).

METHODS

Adults with ≥2 office BP readings and ≥10 awake BP readings on 24-hour ambulatory BP monitoring from 4 pooled US studies were included. We compared mean awake BP with predicted out-of-office BP using PROOF-BP and PROOF-BP-US. Our primary outcomes were hypertensive out-of-office systolic BP (SBP) ≥130 mm Hg and diastolic BP (DBP) ≥80 mm Hg.

RESULTS

We included 3,058 adults, mean (SD) age was 52.0 (11.9) years, 38% were male, and 54% were Black. The area under the receiver-operator characteristic (AUROC) curve (95% confidence interval) for hypertensive out-of-office SBP was 0.81 (0.79-0.82) and DBP was 0.76 (0.74-0.78) for PROOF-BP. For PROOF-BP-US, the AUROC curve for hypertensive out-of-office SBP was 0.82 (0.81-0.83) and for DBP was 0.81 (0.79-0.83). The optimal predicted out-of-office BP ranges for out-of-office BP measurement referral were 120-134/75-84 mm Hg for PROOF-BP and 125-134/75-84 mm Hg for PROOF-BP-US. The 2017 American College of Cardiology/American Heart Association BP guideline (referral range 130-159/80-99 mm Hg) would refer 93.1% of adults not taking antihypertensive medications with office BP ≥130/80 mm Hg in the National Health and Nutrition Examination Survey for out-of-office BP measurement, compared with 53.1% using PROOF-BP and 46.8% using PROOF-BP-US.

CONCLUSIONS

PROOF-BP and PROOF-BP-US accurately predicted out-of-office hypertension in a diverse sample of US adults.

Estimated Pulse Wave Velocity Is Associated With All-Cause Mortality During 8.5 Years Follow-up in Patients Undergoing Elective Coronary Angiography

Background

Estimated pulse wave velocity (ePWV) calculated by equations using age and blood pressure has been suggested as a new marker of mortality and cardiovascular risk. However, the prognostic potential of ePWV during long‐term follow‐up in patients with symptoms of stable angina remains unknown.

Methods and Results

In this study, ePWV was calculated in 25 066 patients without diabetes, previous myocardial infarction (MI), stroke, heart failure, or valvular disease (mean age 63.7±10.5 years, 58% male) with stable angina pectoris undergoing elective coronary angiography during 2003 to 2016. Multivariable Cox models were used to assess the association with incident all‐cause mortality, MI, and stroke. Discrimination was assessed using Harrell´s C‐index. During a median follow‐up period of 8.5 years (interquartile range 5.5–11.3 years), 779 strokes, 1233 MIs, and 4112 deaths were recorded. ePWV was associated with all‐cause mortality (hazard ratio [HR] per 1 m/s, 1.13; 95% CI, 1.05–1.21) and MI (HR per 1 m/s 1.23, 95% CI, 1.09–1.39) after adjusting for age, systolic blood pressure, body mass index, smoking, estimated glomerular filtration rate, Charlson Comorbidity Index score, antihypertensive treatment, statins, aspirin, and number of diseased coronary arteries. Compared with traditional risk factors, the adjusted model with ePWV was associated with a minor but likely not clinically relevant increase in discrimination for mortality, 76.63% with ePWV versus 76.56% without ePWV, P<0.05.

Conclusions

In patients with stable angina pectoris, ePWV was associated with all‐cause mortality and MI beyond traditional risk factors. However, the added prediction of mortality was not improved to a clinically relevant extent.

A model for early failure prediction of blood pressure measurement devices in a stepped validation approach

Blood pressure monitoring (BPM) devices have to be validated according to strict international validation protocols. Each protocol requests a specific number of participants to be included. All protocols use vast amounts of resources, as three people have to be present for every measurement, making trials costly, especially when the manufacturer has no intention to execute a validation study, reflected in the low share of validated in the commercially available BPM devices. The aim of our study was to develop criteria, which could detect low accuracy devices that could not pass a validation protocol early in the course of the validation process. The 2010 European Society of Hypertension International Protocol (ESH-IP) and the Universal Standard for Validation of BPM devices (AAMI/ESH/ISO) were scrutinized for criteria which can be used for preclusion of passing. Based on this, we developed a fail model. We found that a BPM device cannot pass the ESH-IP protocol, if there are ≥27, 13, or 4 single measurements differing more than 5, 10, or 15 mmHg, respectively, from the reference. For the AAMI/ESH/ISO protocol, we developed a model, which calculates best-case standard deviations (SDs) to detect SDs which would prevent the passing of the protocol before its completion, making a stepwise validation process possible. In conclusion, we found that our model is able to predict failure of low-accuracy BPM devices early during a validation protocol if used in a stepwise-approach. This can be useful to keep costs of validation studies low and to enable investigator-initiated trials.

Comparison of supine and seated orthostatic hypotension assessments and their association with falls and orthostatic symptoms

BACKGROUND

Orthostatic hypotension (OH) based on a change from seated-to-standing blood pressure (BP) is often used interchangeably with supine-to-standing BP.

METHODS

The Study to Understand Fall Reduction and Vitamin D in You (STURDY) was a randomized trial of vitamin D3 supplementation and fall in adults aged ≥70 years at high risk of falls. OH was defined as a drop in systolic or diastolic BP of at least 20 or 10 mmHg, measured at pre-randomization, 3-, 12-, and 24-month visits with each of 2 protocols: seated-to-standing and supine-to-standing. Participants were asked about orthostatic symptoms, and falls were ascertained via daily fall calendar, ad hoc reporting, and scheduled interviews.

RESULTS

Among 534 participants with 993 paired supine and seated assessments (mean age 76 ± 5 years, 42% women, 18% Black), mean baseline BP was 130 ± 19/68 ± 11 mmHg; 62% had a history of high BP or hypertension. Mean BP increased 3.5 (SE, 0.4)/2.6 (SE, 0.2) mmHg from sitting to standing, but decreased with supine to standing (mean change: -3.7 [SE, 0.5]/-0.8 [SE, 0.3] mmHg; P-value < 0.001). OH was detected in 2.1% (SE, 0.5) of seated versus 15.0% (SE, 1.4) of supine assessments (P < 0.001). While supine and seated OH were not associated with falls (HR: 1.55 [0.95, 2.52] vs 0.69 [0.30, 1.58]), supine systolic OH was associated with higher fall risk (HR: 1.77 [1.02, 3.05]). Supine OH was associated with self-reported fainting, blacking out, seeing spots and room spinning in the prior month (P-values < 0.03), while sitting OH was not associated with any symptoms (P-values ≥ 0.40).

CONCLUSION

Supine OH was more frequent, associated with orthostatic symptoms, and potentially more predictive of falls than seated OH.

Cuff-Less Blood Pressure Prediction from ECG and PPG Signals Using Fourier Transformation and Amplitude Randomization Preprocessing for Context Aggregation Network Training

This research proposes an algorithm to preprocess photoplethysmography (PPG) and electrocardiogram (ECG) signals and apply the processed signals to the context aggregation network-based deep learning to achieve higher accuracy of continuous systolic and diastolic blood pressure monitoring than other reported algorithms. The preprocessing method consists of the following steps: (1) acquiring the PPG and ECG signals for a two second window at a sampling rate of 125 Hz; (2) separating the signals into an array of 250 data points corresponding to a 2 s data window; (3) randomizing the amplitude of the PPG and ECG signals by multiplying the 2 s frames by a random amplitude constant to ensure that the neural network can only learn from the frequency information accommodating the signal fluctuation due to instrument attachment and installation; (4) Fourier transforming the windowed PPG and ECG signals obtaining both amplitude and phase data; (5) normalizing both the amplitude and the phase of PPG and ECG signals using z-score normalization; and (6) training the neural network using four input channels (the amplitude and the phase of PPG and the amplitude and the phase of ECG), and arterial blood pressure signal in time-domain as the label for supervised learning. As a result, the network can achieve a high continuous blood pressure monitoring accuracy, with the systolic blood pressure root mean square error of 7 mmHg and the diastolic root mean square error of 6 mmHg. These values are within the error range reported in the literature. Note that other methods rely only on mathematical models for the systolic and diastolic values, whereas the proposed method can predict the continuous signal without degrading the measurement performance and relying on a mathematical model.

Validation of a Practical Approach to Blood Pressure Measurement: Secondary Analysis of Data from a Nationally Representative Survey in India

Background

Clinical guidelines differ on the recommended number of blood pressure (BP) measurements for hypertension diagnosis in primary health care settings. We assessed the accuracy in identifying high BP (≥140/90 mmHg) and efficiency (mean BP measures per person in one visit) of a practical BP measurement approach against the research standard.

Methods

We analyzed data from a national survey in India with three BP measurements for each adult participant (N = 372,110). The research standard (referred to as 'standard approach') is measuring three BP and using the mean of the last two. In the practical approach, the first BP reading was used if the measure was <140/90 mmHg; the second BP was used if the first BP was ≥140/90 mmHg. If the difference between either the first two systolic or diastolic BPs was >5 mmHg, then we used the third reading.

Results

Prevalence of high BP was 15.5% and 14.9% using standard and practical approaches, respectively. The sensitivity, specificity, false positive, and false negative rates of the practical approach were 85.4%, 98.0%, 11.3%, and 2.7% compared to the standard approach. The practical approach was more resource-efficient (mean BPs/person/visit 1.4 versus 3.0 for the standard approach). The practical approach had similar validity, but higher efficiency compared to other internationally recommended BP measurement protocols.

Conclusion

The practical BP measurement approach has high validity, is simpler and involves a lower measurement burden on health care providers and can improve the utility of BP measurement, hypertension diagnosis, and management in busy primary health care settings.

Improving hypertension control and cardiovascular health: An urgent call to action for nursing

Background

Hypertension is a leading cause of cardiovascular disease (CVD) and affects nearly one in two adults in the United States when defined as a blood pressure of at least 130/80 mm Hg or on antihypertensive medication (Virani et al., 2021, Circulation, 143, e254). Long‐standing disparities in hypertension awareness, treatment, and control among racial and ethnic populations exist in the United States. High‐quality evidence exists for how to prevent and control hypertension and for the role nurses can play in this effort. In response to the 2020 Surgeon General's Call to Action to Control Hypertension, nursing leaders from 11 national organizations identified the critical roles and actions of nursing in improving hypertension control and cardiovascular health, focusing on evidence‐based nursing interventions and available resources.

Aims

To develop a unified “Call to Action for Nurses” to improve control of hypertension and cardiovascular health and provide information and resources to execute this call.

Methods

This paper outlines roles that registered nurses, advanced practice nurses, schools of nursing, professional nursing organizations, quality improvement nurses, and nursing researchers can play to control hypertension and prevent CVD in the United States. It describes evidence‐based interventions to improve cardiovascular health and outlines actions to bring hypertension and CVD to the forefront as a national priority for nursing.

Linking Evidence to Action

Evidence‐based interventions exist for nurses to lead efforts to prevent and control hypertension, thus preventing much CVD. Nurses can take actions in their communities, their healthcare setting, and their organization to translate these interventions into real‐world practice settings.

Smartphone application-supported validation of three automatic devices for self-measurement of blood pressure according to the European Society of Hypertension International Protocol revision 2010: the Omron HEM-7120, Yuwell YE680A and Cofoe KF-65B

BACKGROUND

Accurate measurement of blood pressure (BP) is crucial to hypertension control and prevention of future stroke and heart attack. All BP measuring devices must be validated independently in the clinical setting.

OBJECTIVE

To validate the accuracy of three automatic upper arm devices (Omron HEM-7120, Yuwell YE680A and Cofoe KF-65B) for self-measurement of BP in Chinese adults with arm size of 22-32 cm.

METHODS

The validation was conducted independently for each of the three devices according to the European Society of Hypertension International Protocol revision 2010 (ESH-IP revision 2010), with the facilitation of a designated smartphone application. Subjects were recruited from those attending Beijing Anzhen Hospital for routine physical examination and clinic visits. For each device, BP was measured sequentially in 33 adults using a mercury sphygmomanometer (two observers) and the test device (one supervisor) with seven measurements alternating between observers and the device, which generated a total of 99 before/after paired values for SBP and DBP separately. The judgments were made based on the distribution of the paired difference among the 99 measurements (Part 1) and among the 33 subjects (Part 2). To pass, a device must achieve all the minimum Pass requirements in Part 1 and Part 2 for both SBP and DBP (Part 3).

RESULTS

Only HEM-7120 achieved the part 1 and part 2 targets for both SBP and DBP. KF-65B achieved the DBP targets of part 1 and part 2 but failed for SBP. YE680A only achieved the DBP targets of part 2 but failed for all others. The findings also indicated that the devices had higher SBP readings (1.3 mmHg, 1.0 mmHg and 4.1 mmHg higher for HEM-7120, YE680A and KF-65B, respectively) and lower DBP readings (2.0 mmHg, 1.1 mmHg and 3.3 mmHg lower, respectively) when compared to the mercury sphygmomanometer.

CONCLUSIONS

The Omron HEM-7120 passed the requirements of the ESH-IP 2010 revision, while the Yuwell YE680A and Cofoe KF-65B failed (part 3).

Unattended compared to traditional blood pressure measurement in patients with rheumatoid arthritis: a randomised cross-over study

BACKGROUND

Hypertension is characterised by a high prevalence, low awareness and poor control among rheumatoid arthritis (RA) patients. Correct blood pressure (BP) measurement is highly important in these subjects. The "unattended" BP measurement aims to reduce the "white-coat effect," a phenomenon associated with cardiovascular risk. Data on "unattended" BP measurement in RA and its impact on hypertensive organ damage are very limited.

METHODS

BP was measured in the same patient both traditionally ("attended" BP) and by the "unattended" protocol (3 automated office BP measurements, at 1-min intervals, after 5 min of rest, with patient left alone) by a randomised cross-over design. Patients underwent clinical examination, 12-lead electrocardiography and trans-thoracic echocardiography to evaluate cardiac damage.

RESULTS

Sixty-two RA patients (mean age 67 ± 9 years, 87% women) were enrolled. Hypertension was diagnosed in 79% and 66% of patients according to ACC/AHA and ESC/ESH criteria, respectively. Concordance correlation coefficients between the two techniques were 0.55 (95%, CI 0.38-0.68) for systolic BP and 0.73 (95%, CI 0.60-0.82) for diastolic BP. "Unattended" (121.7/68.6 mmHg) was lower than "attended" BP (130.5/72.8 mmHg) for systolic and diastolic BP (both p < .0001). Among the two techniques, only "unattended" systolic BP showed a significant association with left ventricular mass (r = 0.11; p = .40 for "attended" BP; r = 0.27; p = .036 for unattended BP; difference between slopes: z = 3.92; p = .0001).

CONCLUSIONS

In RA patients, "unattended" BP is lower than traditional ("attended") BP and more closely associated with LV mass. In these patients, the "unattended" automated BP measurement is a promising tool which requires further evaluation.KEY MESSAGES"Unattended" automated blood pressure registration, aimed to reduce the "white-coat effect" is lower than "attended" value in rheumatoid arthritis patients."Unattended" blood pressure is more closely associated with left ventricular mass than "attende" registration.

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

The present paper provides an update of previous recommendations on Home Blood Pressure Monitoring from the European Society of Hypertension (ESH) Working Group on Blood Pressure Monitoring and Cardiovascular Variability sequentially published in years 2000, 2008 and 2010. This update has taken into account new evidence in this field, including a recent statement by the American Heart association, as well as technological developments, which have occurred over the past 20 years. The present document has been developed by the same ESH Working Group with inputs from an international team of experts, and has been endorsed by the ESH.

Ambulatory blood pressure using 60 rather than 20-min intervals may better reflect the resting blood pressure

PURPOSE

Twenty-four hours of ambulatory blood pressure monitoring (ABPM) is recommended in several guidelines as the best method for diagnosing hypertension. In general, the prognostic value of ABPM is superior to single office blood pressure (BP) measurements. Unfortunately, some patients experience considerable discomfort during frequently repeated forceful cuff inflations.

MATERIALS AND METHODS

In this study we investigated the difference in mean daytime systolic BP (SBP) between low-frequency ABPM (LF-ABPM), measuring once every hour, and high-frequency ABPM (HF-ABPM), measuring three times an hour during daytime, and two times an hour during night-time.

RESULTS

Seventy-one patients were included in the analysis. All included patients had an HF-ABPM performed first and within a few weeks they underwent an LF-ABPM. The average day time difference in SBP between the two frequencies was 3.8 mmHg (p-value = 0.07) for mild, 8.2 mmHg (p-value < 0.01) for moderate and 15 mmHg (p-value < 0.001) for severe hypertension. A similar pattern was seen for night-time SBP. This study suggests that mean BP is similar between the two measuring frequencies for normotensive and mild hypertensive patients, while HF-ABPM results in a higher 24-h mean BP for moderate- and severe hypertensive patients.

CONCLUSION

LF-ABPM may more correctly reflect the resting blood pressure in patients with moderate and severe hypertension.

Detection of Atrial Fibrillation Using a Home Blood Pressure Monitor

PURPOSE

Atrial fibrillation (AF) is the most common arrhythmia and is associated with an increased risk of complications. A screening test has the potential to prevent AF-related complications. This study investigated the diagnostic accuracy of an automated device for home blood pressure (BP) monitoring, which implements an algorithm for AF detection.

PATIENTS AND METHODS

A modified, automated oscillometric device for home BP monitoring (Omron BP785N (HEM-7321-Z), Omron Healthcare) with an AF detector was used to measure the BP in patients. During each BP measurements, the electrocardiogram (ECG) was recorded simultaneously. Simultaneous BP measurements and ECG recordings were obtained from 99 subjects.

RESULTS

Twenty out of 20 patients with atrial fibrillation were correctly recognized by the device and the device correctly identified 67 patients with sinus rhythm as "Not-AF". On the other hand, 12 patients with basic rhythm: sinus rhythm were incorrectly referred to as "atrial fibrillation". In summary, the device has a diagnostic accuracy of 87.88% with a sensitivity of 100% and a specificity of 84.8%. On the other hand, in 23 patients, the raw data of the device showed that a body movement occurred during the measurement of the blood pressure. If these subjects were excluded of the analysis, then the diagnostic accuracy of the device would be even better, namely 90.79%. The sensitivity would be 100% and the specificity 89.5%.

CONCLUSION

These data suggest that an automated device for home blood pressure has an excellent diagnostic accuracy for detecting an AF and could be used as a reliable screening test for early diagnosis of atrial fibrillation. Body movements have an impact of the accuracy and specificity of a blood pressure monitor.

Precision-Microfabricated Fiber-Optic Probe for Intravascular Pressure and Temperature Sensing

Small form-factor sensors are widely used in minimally invasive intravascular diagnostic procedures. Manufacturing complexities associated with miniaturizing current fiber-optic probes, particularly for multi-parameter sensing, severely constrain their adoption outside of niche fields. It is especially challenging to rapidly prototype and iterate upon sensor designs to optimize performance for medical devices. In this work, a novel technique to construct a microscale extrinsic fiber-optic sensor with a confined air cavity and sub-micron geometric resolution is presented. The confined air cavity is enclosed between a 3 μm thick pressure-sensitive distal diaphragm and a proximal temperature-sensitive plano-convex microlens segment unresponsive to changes in external pressure. Simultaneous pressure and temperature measurements are possible through optical interrogation via phase-resolved low-coherence interferometry (LCI). Upon characterization in a simulated intravascular environment, we find these sensors capable of detecting pressure changes down to 0.11 mmHg (in the range of 760 to 1060 mmHg) and temperature changes of 0.036 °C (in the range 34 to 50 °C). By virtue of these sensitivity values suited to intravascular physiological monitoring, and the scope of design flexibility enabled by the precision-fabricated photoresist microstructure, it is envisaged that this technique will enable construction of a wide range of fiber-optic sensors for guiding minimally invasive medical procedures.

Blended Learning on Blood Pressure Measurement: Investigating Two In-Class Strategies in a Flipped Classroom-Like Setting to Teach Pharmacy Students Blood Pressure Measurement Skills

For reliable blood pressure measurement, various potential sources of inaccuracies need to be considered to avoid incorrect decision-making. Pharmacy students should be sensitized and taught the skill accordingly. One strategy to teach students’ blood pressure measurement skills might be through a blended learning approach in a flipped classroom-like setting. With a randomized two-arm study among pharmacy students in their eighth semester, the required extent of in-class session in the scope of a blended learning approach in a flipped classroom-like setting was evaluated. Participants’ self-confidence and self-perceived proficiency were evaluated through a survey, and participants’ blood pressure measurement performance was assessed by objective structured clinical examination (OSCE). Participants’ satisfaction with, and perception of, the flipped classroom were also surveyed. The extended in-class activities did not result in a significantly higher increase of participants’ OSCE score and self-assessment score when compared to the brief in-class session. Both in-class sessions yielded a significant increase in the OSCE scores as well as in the self-assessment scores. Moreover, the teaching approaches were predominantly well-received by the students. The use of both flipped classroom-like approaches improved pharmacy students’ blood pressure measurement performance, though the brief in-class session was sufficient. Students’ self-confidence/self-perceived proficiency in blood pressure measurement skills increased similarly in both settings.

Twenty-Four-Hour Ambulatory Blood Pressure Monitoring

The diagnosis, management, and estimated mortality risk in patients with hypertension have been historically based on clinic or office blood pressure readings. Current evidence indicates that 24-hour ambulatory blood pressure monitoring should be an integral part of hypertension care. The 24-hour ambulatory monitors currently available on the market are small devices connected to the arm cuff with tubing that measure blood pressure every 15 to 30 minutes. After 24 hours, the patient returns, and the data are downloaded, including any information requested by the physician in a diary. The most useful information includes the 24-hour average blood pressure, the average daytime blood pressure, the average nighttime blood pressure, and the calculated percentage drop in blood pressure at night. The most widely used criteria for 24-hour measurements are from the American Heart Association 2017 guidelines and the European Society of Hypertension 2018 guidelines. Two important scenarios described in this document are white coat hypertension, in which patients have normal blood pressures at home but high blood pressures during office visits, and masked hypertension, in which patients are normotensive in the clinic but have high blood pressures outside of the office. The Centers for Medicare and Medicaid Services has made changes in its policy to allow reimbursement for a broader use of 24-hour ambulatory blood pressure monitoring within some specific guidelines. Primary care physicians should make more use of ambulatory blood pressure monitoring, especially in patients with difficult to manage hypertension.

The Development of an Educational Video on Blood Pressure Measurement for Pharmacy Students

INTRODUCTION

High blood pressure is an important worldwide health issue. Pharmacists can perform multifaceted tasks in hypertension management such as measuring blood pressure. In a time where the use of educational videos in health professions education has increased, an educational video might be an option for teaching blood pressure measurement skills to pharmacy students. This project aimed to develop an educational video tailored to pharmacy students on oscillometric blood pressure measurement in a community pharmacy setting that can be used as a self-instruction video.

METHODS

The video was created with support from the university's multimedia center. The video development was roughly divided into pre-production, production, and post-production. Students' satisfaction with and perception of the video was surveyed.

RESULTS

An 11-minute 33-second self-instruction video in the German language on proper oscillometric blood pressure measurement tailored for pharmacy students was created. Along with descriptive slides, the video delineates the necessary steps of blood pressure measurement in a community pharmacy setting in a role-play, to support students in communication with the patient. Results of a survey on the satisfaction and perception of the video from thirty-seven pharmacy students were included in the analysis and revealed that the video was well accepted by pharmacy students. Moreover, approximately 95% responded that instructional videos should be included in future pharmacy education.

CONCLUSION

We successfully developed an educational video on oscillometric blood pressure measurement for a community pharmacy setting. This work is a valuable form of support for faculty members, who intend to develop educational videos. This might be of interest especially during the coronavirus disease 2019 (COVID-19) pandemic, where distance learning has become highly relevant.

Comprehensive Review on Triboelectric Nanogenerator Based Wrist Pulse Measurement: Sensor Fabrication and Diagnosis of Arterial Pressure

As the world is marching into the era of the Internet of things (IoTs) and artificial intelligence (AI), the most vital requirement for reliable hardware development is an ultrafast response time and no performance degradation. As a reliable indicator of human physiological health, blood pressure measurement is vital in humans' daily lives, which creates a huge demand in monitoring and diagnosing blood pressure problems. The triboelectric nanogenerator (TENG) is one of the best energy devices and healthcare applications in the new era since triboelectrification is a universal and ubiquitous effect with an abundant choice of materials. TENG is reliable in physiological monitoring applications and has many benefits, including being inexpensive, easy to manufacture, and lightweight, having self-powered properties, and being available in a wide range of materials. In this review, triboelectric nanogenerator based wrist pulse measurement was summarized for blood pressure monitoring and diagnosis applications. As per the Ayurveda, imbalance in three essential components of the wrist pulse implies the human health status and reveals symptoms for diseases. The design of different TENG-based blood pressure sensors, sensing mechanisms, performance, merits, and demerits of each method are discussed.

Digit Preference in Office Blood Pressure Measurements, United States 2015-2019

BACKGROUND

Blood pressure (BP) measurement error may lead to under- or overtreatment of hypertension. One common source of error is terminal digit preference, most often a terminal digit of "0." The objective was to evaluate national trends in terminal digit preference in office BP measurements among adults with treated hypertension.

METHODS

Data were from IQVIA's National Disease and Therapeutic Index, a nationally representative, serial cross-sectional survey of office-based physicians. The analysis included office visits from 2015 to 2019 among adults aged ≥18 years receiving antihypertensive treatment. Annual trends were examined in the percent of systolic and diastolic BP measurements ending in zero by patient sex, age, and race/ethnicity, physician specialty, and first or subsequent hypertension treatment visit.

RESULTS

From 2015 to 2019, there were ~60 million hypertension treatment visits annually (unweighted N: 5,585-9,085). There was a decrease in the percent of visits with systolic (41.7%-37.7%) or diastolic (42.7%-37.8%) BP recordings ending in zero. Trends were similar by patient characteristics. However, a greater proportion of measurements ended in zero among patients aged ≥80 (vs. 15-59 or 60-79) years, first (vs. subsequent) treatment visits, visits to cardiologists (vs. primary care physicians), and visits with systolic BP ≥140 or diastolic BP ≥90 (vs. <140/90) mm Hg.

CONCLUSIONS

Despite modest improvement, terminal digit preference remains a common problem in office BP measurement in the United States. Without bias, 10%-20% of measurements are expected to end in zero. Reducing digit preference is a priority for improving BP measurement accuracy and hypertension management.

Cuffless Blood Pressure Measurement Using a Smartphone-Case Based ECG Monitor with Photoplethysmography in Hypertensive Patients

The availability of simple, accurate, and affordable cuffless blood pressure (BP) devices has the potential to greatly increase the compliance with measurement recommendations and the utilization of BP measurements for BP telemonitoring. The aim of this study is to evaluate the correlation between findings from routine BP measurements using a conventional sphygmomanometer with the results from a portable ECG monitor combined with photoplethysmography (PPG) for pulse wave registration in patients with arterial hypertension.

METHODS

The study included 500 patients aged 32-88 years (mean 64 ± 7.9 years). Mean values from three routine BP measurements by a sphygmomanometer with cuff were selected for comparison; within one minute after the last measurement, an electrocardiogram (ECG) was recorded for 3 min in the standard lead I using a smartphone-case based single-channel ECG monitor (CardioQVARK^®-limited responsibility company "L-CARD", Moscow, Russia) simultaneously with a PPG pulse wave recording. Using a combination of the heart signal with the PPG, levels of systolic and diastolic BP were determined based on machine learning using a previously developed and validated algorithm and were compared with sphygmomanometer results.

RESULTS

According to the Bland-Altman analysis, SD for systolic BP was 3.63, and bias was 0.32 for systolic BP. SD was 2.95 and bias was 0.61 for diastolic BP. The correlation between the results from the sphygmomanometer and the cuffless method was 0.89 (p = 0.001) for systolic and 0.87 (p = 0.002) for diastolic BP.

CONCLUSION

Blood pressure measurements on a smartphone-case without a cuff are encouraging. However, further research is needed to improve the accuracy and reliability of clinical use in the majority of patients.

Web-Based Smartphone Algorithm for Calculating Blood Pressure From Photoplethysmography Remotely in a General Adult Population: Validation Study

BACKGROUND

Outside of a clinical setting, oscillometric devices make remote monitoring of blood pressure and virtual care more convenient and feasible. HeartBeat Technologies Ltd developed a novel approach to measuring blood pressure remotely after an initial blood pressure reading by a nurse using the conventional measurement method. Using a finger pulse oximeter, a photoplethysmogram wave is transmitted by Bluetooth to a smartphone or tablet. A smartphone app (MediBeat) transmits the photoplethysmogram to a server for analysis by a proprietary algorithm-the person's current blood pressure is sent back to the smartphone and to the individual's health care provider.

OBJECTIVE

This study sought to determine whether the HeartBeat algorithm calculates blood pressure as accurately as required by the European Society of Hypertension International Protocol revision 2010 (ESH-IP2) for validation of blood pressure measuring devices.

METHODS

ESH-IP2 requirements, modified to conform to a more recent international consensus statement, were followed. The ESH-IP2 establishes strict guidelines for the conduct and reporting of any validation of any device to measure blood pressure, including using the standard manual blood pressure instrument as a comparator and specific required accuracy levels for low, medium, and high ranges of blood pressure readings. The consensus statement requires a greater number of study participants for each of the blood pressure ranges. The validation of the accuracy of the algorithm was conducted with a Contec CMS50EW pulse oximeter and a Samsung Galaxy XCover 4 smartphone.

RESULTS

The differences between the HeartBeat-calculated and the manually measured blood pressures of 62 study participants did not meet the ESH-IP2 standards for accuracy for either systolic or diastolic blood pressure measurements. There was no discernible pattern in the inaccuracies of the HeartBeat-calculated measurements.

CONCLUSIONS

The October 4, 2019 version of the HeartBeat algorithm, implemented in combination with the MediBeat app, a pulse oximeter, and an Android smartphone, was not sufficiently accurate for use in a general adult population.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04082819; http://clinicaltrials.gov/ct2/show/NCT04082819.

Blood Pressure in Childhood and Adolescence

Elevated blood pressure (BP) and hypertension commonly occur in children and adolescents and increase the risk of cardiovascular disease in adulthood. The purpose of this review is to summarize recent research in pediatric hypertension including changes in defining hypertension, BP measurement techniques, hypertension epidemiology, risk factors, treatment, and BP-related target organ damage. Defining pediatric hypertension using the 2017 American Academy of Pediatrics' updated Clinical Practice Guideline resulted in a larger proportion of children being classified as having elevated BP or hypertension compared with prior guidelines. Trends in the distribution of BP among US children and adolescents suggest that BP levels and the prevalence of hypertension may have increased from 2011-2014 to 2015-2018. Factors including a family history of hypertension, obesity, minority race/ethnicity, physical inactivity, high dietary intake of sodium, and poor sleep quality are associated with an increased prevalence of elevated BP and hypertension. Evidence of a linear relationship between systolic BP and target organ damage indicates that BP levels currently considered normal could increase the risk of target organ damage in childhood. Lifestyle changes, such as adhering to the Dietary Approaches to Stop Hypertension diet, are a central component of effectively reducing BP and have been shown to reduce target organ damage. Pharmacologic treatment using angiotensin-converting enzyme inhibitors and angiotensin receptor blockers is an effective and safe method for reducing BP among children with uncontrolled BP after implementing lifestyle changes. Research gaps in the prevention, detection, classification, and treatment of hypertension in children demonstrate opportunities for future study.

Executive summary of the KDIGO 2021 Clinical Practice Guideline for the Management of Blood Pressure in Chronic Kidney Disease

The Kidney Disease: Improving Global Outcomes (KDIGO) 2021 Clinical Practice Guideline for the Management of Blood Pressure in Chronic Kidney Disease for patients not receiving dialysis represents an update to the KDIGO 2012 guideline on this topic. Development of this guideline update followed a rigorous process of evidence review and appraisal. Guideline recommendations are based on systematic reviews of relevant studies and appraisal of the quality of the evidence. The strength of recommendations is based on the "Grading of Recommendations Assessment, Development and Evaluation" (GRADE) approach. The scope includes topics covered in the original guideline, such as optimal blood pressure targets, lifestyle interventions, antihypertensive medications, and specific management in kidney transplant recipients and children. Some aspects of general and cardiovascular health, such as lipid and smoking management, are excluded. This guideline also introduces a chapter dedicated to proper blood pressure measurement since all large randomized trials targeting blood pressure with pivotal outcomes used standardized preparation and measurement protocols adhered to by patients and clinicians. Based on previous and new evidence, in particular the Systolic Blood Pressure Intervention Trial (SPRINT) results, we propose a systolic blood pressure target of less than 120 mm Hg using standardized office reading for most people with chronic kidney disease (CKD) not receiving dialysis, the exception being children and kidney transplant recipients. The goal of this guideline is to provide clinicians and patients a useful resource with actionable recommendations supplemented with practice points. The burden of the recommendations on patients and resources, public policy implications, and limitations of the evidence are taken into consideration. Lastly, knowledge gaps and recommendations for future research are provided.

How Should We Measure and Deal with Office Blood Pressure in 2021?

Arterial hypertension is a major risk factor for cardiovascular disease worldwide. Office blood pressure measurements (OBPMs) are still recommended for diagnosis and follow-up by all major guidelines; however, the recommended procedures differ significantly. In analogy, major outcome studies usually apply OBPMs, again, with a variety of procedures. This variety of OBPM procedures complicates the comparability between studies and challenges daily clinical practice. In this narrative review, we compile the most recent recommendations for office blood pressure measurement together with the major limitations and strategies and how these could be overcome.

Self-Instruction Video Versus Face-to-Face Instruction of Pharmacy Students' Skills in Blood Pressure Measurement

A modern approach to clinical skill education is the use of educational videos, yet there is a shortage of literature investigating the effect of self-instruction videos (SIVs) in pharmacy students. Therefore, our objective was to investigate whether an SIV is non-inferior compared to face-to-face instruction (FTFI) in acquiring blood pressure measurement skills. The participants in this randomized controlled study were pharmacy students. The control group was taught by FTFI, while the intervention group watched an SIV. Before and after the instruction, the participants' performance was assessed by an objective structured clinical examination (OSCE). The participants completed a self-assessment survey before each OSCE session. Moreover, the participants' perception and satisfaction were assessed using another survey. The OSCE score and self-assessment score increased significantly from pre- to post-instruction in both groups. The SIV was non-inferior compared to FTFI in terms of the OSCE score, considering a predefined non-inferiority margin of -10%. The participants' self-assessment yielded inconclusive results for non-inferiority. Both instructional approaches were well received. Considering our findings, SIVs might be a valuable option for teaching pharmacy students' blood pressure measurement skills. However, depending on the skill intended to be taught, a combination of an instructional video with instructor-led teaching may be necessary.