Validation of the Raycome model M2 ambulatory blood pressure monitor in the general population according to the Association for the Advancement of Medical Instrumentation/European Society of Hypertension/International Organization for Standardization Universal Standard (ISO 81060-2:2018)

OBJECTIVE

The aim of this study was to evaluate the accuracy of the Raycome model M2 oscillometric upper-arm blood pressure (BP) monitor developed for ambulatory BP measurement in the general population according to 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) at rest and during dynamic exercise.

METHOD

Subjects were recruited to fulfill the age, gender, BP and cuff distribution criteria of the AAMI/ESH/ISO Universal Standard in the general population using the same arm sequential BP measurement method. Three cuffs of the test device were used for arm circumference 18-22 cm (small), 22-32 cm (medium) and 32-42 cm (large).

RESULTS

For the general validation study, 106 subjects were recruited and 85 were analyzed. For validation criterion 1, the mean ± SD of the differences between the test device and reference BP readings was 0.5 ± 6.2/-0.2 ± 5.1 mmHg (systolic/diastolic). For criterion 2, the SD of the mean BP differences between the test device and reference BP per subject was 5.23/4.50 mmHg (systolic/diastolic). In the ambulatory validation study ( N  = 35), the mean difference was 0.4 ± 5.9/-1.1 ± 5.8 mmHg. The Raycome model M2 performed well against the standard in both the general and ambulatory validations and the Bland-Altman plots did not show any systematic variation in the error.

CONCLUSION

These data show that the Raycome model M2 monitor meets the requirements of the AAMI/ESH/ISO Universal Standard (ISO 81060-2:2018) and in the ambulatory setting, indicating its suitability for measuring BP in the general population.

Comparing ChatGPT and Bing, in response to the Home Blood Pressure Monitoring (HBPM) knowledge checklist

High blood pressure is one of the major public health problems that is prevalent worldwide. Due to the rapid increase in the number of users of artificial intelligence tools such as ChatGPT and Bing, it is expected that patients will use these tools as a source of information to obtain information about high blood pressure. The purpose of this study is to check the accuracy, completeness, and reproducibility of answers provided by ChatGPT and Bing to the knowledge questionnaire of blood pressure control at home. In this study, ChatGPT and Bing's responses to the HBPM 10-question knowledge checklist on blood pressure measurement were independently reviewed by three cardiologists. The mean accuracy rating of ChatGPT was 5.96 (SD = 0.17) indicating the responses were highly accurate overall, with the vast majority receiving the top score. The mean accuracy and completeness of ChatGPT were 5.96 (SD = 0.17) and 2.93 (SD = 0.25) and in Bing were 5.31 (SD = 0.67), and 2.13 (SD = 0.53) Respectively. Due to the expansion of artificial intelligence applications, patients can use new tools such as ChatGPT and Bing to search for information and at the same time can trust the information obtained. we found that the answers obtained from ChatGPT are reliable and valuable for patients, while Bing is also considered a powerful tool, it has more limitations than ChatGPT, and the answers should be interpreted with caution.

Availability, Cost, and Consumer Ratings of Popular Nonvalidated vs Validated Blood Pressure-Measuring Devices Sold Online in 10 Countries

This study examines the availability, cost, and consumer ratings of blood pressure–measuring devices relative to validation status across 10 countries.

Physician perceived barriers and facilitators for self-measured blood pressure monitoring- a qualitative study

INTRODUCTION

Improving hypertension management is a national priority that can decrease morbidity and mortality. Evidence-based hypertension management guidelines advocate self-measured BP (SMBP), but widespread implementation of SMBP is lacking. The purpose of this study was to describe the perspective of primary care physicians (PCPs) on SMBP to identify the barriers and facilitators for implementing SMBP.

METHODS

We collected data from PCPs from a large health system using semi-structured interviews based on the Theoretical Domains Framework (TDF). Responses were recorded, transcribed, and qualitatively analyzed into three overarching TDF domains based on the Behavior Change Wheel (BCW): 1) Motivation 2) Opportunity and 3) Capabilities. The sample size was based on theme saturation.

RESULTS

All 17 participating PCPs believed that SMBP is a useful, but underutilized tool. Although individual practices varied, most physicians felt that the increased data points from SMBP allowed for better hypertension management. Most felt that overcoming existing barriers would be difficult, but identified several facilitators: physician support of SMBP, the possibility of having other trained health professionals to assist with SMBP and patient education; improving patient engagement and empowerment with SMBP, and the interest of the health system in using technology to improve hypertension management.

CONCLUSION

PCPs believe that SMBP can improve hypertension management. There are numerous barriers and facilitators for implementing SMBP. Successful implementation in clinical practice will require implementation strategies targeted at increasing patient acceptability and reducing physician workload. This may need a radical change in the current methods of managing hypertension.

Home blood pressure monitoring in the diagnosis and treatment of hypertension in pregnancy: a systematic review and meta-analysis

BACKGROUND

Home blood pressure monitoring is increasingly used for pregnant individuals; however, there are no guidelines on such monitoring in this population. We assessed current practices in the prescription and use of home blood pressure monitoring in pregnancy.

METHODS

We conducted a systematic review and meta-analysis of observational studies and randomized controlled trials (RCTs). We conducted a structured search through the MEDLINE (from 1946), Embase (from 1974) and CENTRAL (from 2018) databases up to Oct. 19, 2020. We included trials comparing office and home blood pressure monitoring in pregnant people. Outcomes included patient education, home blood pressure device, monitoring schedule, adherence, diagnostic thresholds for home blood pressure, and comparison between home and office measurements of blood pressure.

RESULTS

We included in our review 21 articles on 19 individual studies (1 RCT, 18 observational) that assessed home and office blood pressure in pregnant individuals (n = 2843). We observed variation in practice patterns in terms of how home monitoring was prescribed. Eight (42%) of the studies used validated home blood pressure devices. Across all studies, measurements were taken 3 to 36 times per week. Third-trimester home blood pressure corresponding to office blood pressure of 140/90 mm Hg after application of a conversion factor ranged from 118 to 143 mm Hg (systolic) and from 76 to 92 mm Hg (diastolic), depending on the patient population and methodology. Systolic and diastolic blood pressure values measured at home were lower than office values by 4 (95% confidence interval [CI] -6 to -3) mm Hg and 3 (95% CI -4 to -2) mm Hg, respectively.

INTERPRETATION

Many issues related to home blood pressure monitoring in pregnancy are currently unresolved, including technique, monitoring schedule and target values. Future studies should prioritize the use of validated home measuring devices and standardized measurement schedules and should establish treatment targets.

PROSPERO REGISTRATION

CRD42020147352.

Comparison of Pediatric and Adult Ambulatory Blood Pressure Monitoring Criteria for the Diagnosis of Hypertension and Detection of Left Ventricular Hypertrophy in Adolescents

OBJECTIVE

To compare pediatric ambulatory blood pressure monitoring (ABPM) criteria with adult ABPM criteria for the diagnosis of hypertension and detection of left ventricular hypertrophy (LVH) in adolescents.

STUDY DESIGN

ABPM and echocardiography reports from adolescents age 13-21 years from 2015 to 2019 were analyzed. The concordance of hypertension based on pediatric criteria (American Heart Association 2014) was compared with adult criteria from American College of Cardiology/American Heart Association 2017 (overall BP ≥125/75 mm Hg, wake BP ≥130/80 mm Hg, sleep BP ≥110/65 mm Hg) using the Cohen kappa statistic. Logistic regression, adjusted for body mass index z score, and receiver operating characteristic curves (ROCs) compared pediatric criteria vs adult criteria in predicting LVH (left ventricular mass index >95th percentile reference values and left ventricular mass index >51 g/m^2.7).

RESULTS

Of 306 adolescents, 140 (45.8%) had hypertension based on pediatric criteria vs 228 (74.5%) based on adult criteria; the agreement was poor (59.3%, n = 137, kappa = 0.41). A higher prevalence of LVH was captured by adult criteria only (n = 91) compared with pediatric criteria only (n = 3). Logistic regression found no significant differences between pediatric and adult criteria in the detection of LVH >95th percentile (OR 1.24, CI 0.66, 2.31, P = .51) or >51 g/m^2.7 (OR 1.06, CI 0.47, 2.40, P = .89). ROCs for pediatric criteria were not significant for detecting LVH >95th percentile (0.50, P = .91) or >51 g/m^2.7 (0.55, P = .45), whereas the ROC for adult criteria was significant for detecting LVH >95th percentile (0.59, P = .045) but not >51 g/m^2.7 (0.63, P = .07). Although all individuals with LVH >51 g/m^2.7 were hypertensive by adult criteria, 8 of these individuals were missed by pediatric criteria.

CONCLUSIONS

Adult criteria captured a higher prevalence of LVH and appeared to predict better LVH than pediatric criteria. A consideration to align ABPM criteria for diagnosing hypertension in adolescents with adult guidelines is warranted.

Home and Online Management and Evaluation of Blood Pressure (HOME BP) using a digital intervention in poorly controlled hypertension: randomised controlled trial

OBJECTIVE

The HOME BP (Home and Online Management and Evaluation of Blood Pressure) trial aimed to test a digital intervention for hypertension management in primary care by combining self-monitoring of blood pressure with guided self-management.

DESIGN

Unmasked randomised controlled trial with automated ascertainment of primary endpoint.

SETTING

76 general practices in the United Kingdom.

PARTICIPANTS

622 people with treated but poorly controlled hypertension (>140/90 mm Hg) and access to the internet.

INTERVENTIONS

Participants were randomised by using a minimisation algorithm to self-monitoring of blood pressure with a digital intervention (305 participants) or usual care (routine hypertension care, with appointments and drug changes made at the discretion of the general practitioner; 317 participants). The digital intervention provided feedback of blood pressure results to patients and professionals with optional lifestyle advice and motivational support. Target blood pressure for hypertension, diabetes, and people aged 80 or older followed UK national guidelines.

MAIN OUTCOME MEASURES

The primary outcome was the difference in systolic blood pressure (mean of second and third readings) after one year, adjusted for baseline blood pressure, blood pressure target, age, and practice, with multiple imputation for missing values.

RESULTS

After one year, data were available from 552 participants (88.6%) with imputation for the remaining 70 participants (11.4%). Mean blood pressure dropped from 151.7/86.4 to 138.4/80.2 mm Hg in the intervention group and from 151.6/85.3 to 141.8/79.8 mm Hg in the usual care group, giving a mean difference in systolic blood pressure of -3.4 mm Hg (95% confidence interval -6.1 to -0.8 mm Hg) and a mean difference in diastolic blood pressure of -0.5 mm Hg (-1.9 to 0.9 mm Hg). Results were comparable in the complete case analysis and adverse effects were similar between groups. Within trial costs showed an incremental cost effectiveness ratio of £11 ($15, €12; 95% confidence interval £6 to £29) per mm Hg reduction.

CONCLUSIONS

The HOME BP digital intervention for the management of hypertension by using self-monitored blood pressure led to better control of systolic blood pressure after one year than usual care, with low incremental costs. Implementation in primary care will require integration into clinical workflows and consideration of people who are digitally excluded.

TRIAL REGISTRATION

ISRCTN13790648.

Short-term reproducibility of ambulatory blood pressure measurements: a systematic review and meta-analysis of 35 observational studies

OBJECTIVE

A systematic review on the reproducibility of ambulatory blood pressure measurements (ABPM) has not yet been conducted. This meta-analysis compared 24-h/daytime/night-time SBP and DBP mean values and SBP/DBP nocturnal dipping status from ABPMs in participants with or without hypertension.

METHODS

Ovid MEDLINE, EMBASE, and CINAHL Complete databases were searched for articles published before 3 May 2019. Eligible studies reporting a 24-h ABPM repeated at least once within 1 month were included. The mean daytime/night-time/24-h BP values, percentage of nocturnal dipping, and proportion of nondippers were compared between the first and second day of measurements, and the proportion of participants with inconsistent dipping status were estimated using a random effect model.

RESULTS

Population-based analysis found a 0-1.1 mmHg difference between the first and second ABPM for 24-h/daytime/night-time SBP and DBP and 0-0.5% for percentage of SBP/DBP nocturnal dipping. The proportion of non-dippers was not different between the first and second ABPM. Intra-individual analysis found that the 95% limit of agreements (LOA) for SBP/DBP were wide and the 95% LOA for daytime SBP, common reference to diagnose hypertension, ranged -16.7 to 18.4 mmHg. Similarly, 32% of participants had inconsistent nocturnal dipping status.

CONCLUSION

ABPM had excellent reproducibility at the population level, favouring its application for research purposes; but reproducibility of intra-individual BP values and dipping status from a 24-h ABPM was limited. The available evidence was limited by the lack of high-quality studies and lack of studies in non-Western populations.

Self-Measured Blood Pressure Monitoring at Home: A Joint Policy Statement From the American Heart Association and American Medical Association

The diagnosis and management of hypertension, a common cardiovascular risk factor among the general population, have been based primarily on the measurement of blood pressure (BP) in the office. BP may differ considerably when measured in the office and when measured outside of the office setting, and higher out-of-office BP is associated with increased cardiovascular risk independent of office BP. Self-measured BP monitoring, the measurement of BP by an individual outside of the office at home, is a validated approach for out-of-office BP measurement. Several national and international hypertension guidelines endorse self-measured BP monitoring. Indications include the diagnosis of white-coat hypertension and masked hypertension and the identification of white-coat effect and masked uncontrolled hypertension. Other indications include confirming the diagnosis of resistant hypertension and detecting morning hypertension. Validated self-measured BP monitoring devices that use the oscillometric method are preferred, and a standardized BP measurement and monitoring protocol should be followed. Evidence from meta-analyses of randomized trials indicates that self-measured BP monitoring is associated with a reduction in BP and improved BP control, and the benefits of self-measured BP monitoring are greatest when done along with cointerventions. The addition of self-measured BP monitoring to office BP monitoring is cost-effective compared with office BP monitoring alone or usual care among individuals with high office BP. The use of self-measured BP monitoring is commonly reported by both individuals and providers. Therefore, self-measured BP monitoring has high potential for improving the diagnosis and management of hypertension in the United States. Randomized controlled trials examining the impact of self-measured BP monitoring on cardiovascular outcomes are needed. To adequately address barriers to the implementation of self-measured BP monitoring, financial investment is needed in the following areas: improving education and training of individuals and providers, building health information technology capacity, incorporating self-measured BP readings into clinical performance measures, supporting cointerventions, and enhancing reimbursement.

The implications of blood pressure targets from the 2018 European Society of Cardiology hypertension guidelines in Asian patients: a systematic review and meta-analysis

BACKGROUND

The evidence for optimal blood pressure (BP) targets in Asian patients with hypertension is insufficient and controversial. Western guidelines should be used with caution in clinical practice until there is supporting evidence.

OBJECTIVE

Systematically synthesize the evidence on the efficacy of achieving the strict 2018 European Society of Cardiology (ESC) guideline BP targets versus standard BP targets in Asian patients.

DATA SOURCES

We searched PubMed, Web of Science, Scopus, the Cochrane Central Register of controlled trials, and additional databases to retrieve relevant Asian studies.

STUDY SELECTION

Randomized controlled trials (RCTs) and observational studies that reported clinical endpoints, had a minimal follow-up period of one year and included Asian patients older than 18 years with essential hypertension.

DATA EXTRACTION

Two investigators independently conducted the study selection with any discrepancies resolved between team members.

DATA SYNTHESIS

We selected 15 studies for analysis (4 RCTs, 7 observational studies, and 4 post-hoc analyses). The evidence for the strict BP targets in elderly patients was insufficient. In middle-aged patients, the meta-analysis of observational studies revealed a significant reduction in major adverse cardiac events (MACCE) (hazard ratio (HR)=0.78; 95% confidence interval (CI: 0.74-0.81). For studies that reported results for patients of any age, the tight systolic BP-lowering therapy was associated with a decrease in MACCE (HR=0.80; 95% CI: 0.69-0.92), stroke (HR=0.82; 95% CI: 0.71-0.94), but not in cardiac events (HR=0.91; 95% CI: 0.72-1.14, P=.41), all-cause (HR=0.80; 95% CI: 0.57-1.13) and cardiovascular mortality (HR=0.73; 95% CI: 0.40-1.33, P=.30). Similar findings were obtained for the strict diastolic BP targets.

CONCLUSION

Our findings provide evidence for Asian patients that support the efficacy of the strict antihypertensive treatment with BP targets proposed by the 2018 ESC hypertension guidelines for the prevention of cardiovascular events. However, these data were obtained from only observational studies and the results were not confirmed by RCTs, probably due to insufficient power. Therefore, further high-quality RCTs are crucial.

LIMITATIONS

Use of aggregated data, the subgroup and meta-regression analyses are inconclusive, limited to English language, unable to estimate summary measures for some outcomes, publication bias difficult to assess, and unclear that results could be extrapolated.

REGISTRATION

The protocol registered in PROSPERO (CRD42018115570).

CONFLICT OF INTEREST

None.

Recommendations for exercise and screening for safe athletic participation in hypertensive youth

Physical activity is an important component of ideal cardiovascular health. Current guidelines recommend that youth with hypertension participate in competitive sports once hypertensive target organ effects and risks have been assessed and that children with hypertension receive treatment to lower BP below stage 2 thresholds (e.g., < 140/90 mmHg or < 95th percentile + 12 mmHg) before participating in competitive sports. Despite these recommendations, pediatricians and pediatric subspecialists continue to struggle with how best to counsel their patients regarding appropriate forms of physical activity, the impact of exercise on blood pressure, and how best to screen for cardiovascular conditions that place youth at risk for sudden cardiac death. This review provides a summary of our current knowledge regarding the safety and utility of exercise in the management of high blood pressure in youth. We review determinants of blood pressure during exercise, the impact of blood pressure on cardiovascular health and structure, mechanisms for assessing cardiometabolic fitness (e.g., exercise stress test), contraindications to athletic participation, and how best to plan for athletic participation among hypertensive youth. Greater knowledge in these areas may offer clarity to providers faced with the challenge of prescribing exercise recommendations for hypertensive youth.

Screening for Hypertension in the INpatient Environment(SHINE): a protocol for a prospective study of diagnostic accuracy among adult hospital patients

INTRODUCTION

A significant percentage of patients admitted to hospital have undiagnosed hypertension. However, present hypertension guidelines in the UK, Europe and USA do not define a blood pressure threshold at which hospital inpatients should be considered at risk of hypertension, outside of the emergency setting. The objective of this study is to identify the optimal in-hospital mean blood pressure threshold, above which patients should receive postdischarge blood pressure assessment in the community.

METHODS AND ANALYSIS

Screening for Hypertension in the INpatient Environment is a prospective diagnostic accuracy study. Patients admitted to hospital whose mean average daytime blood pressure after 24 hours or longer meets the study eligibility threshold for mean daytime blood pressure (≥120/70 mm Hg) and who have no prior diagnosis of, or medication for hypertension will be eligible. At 8 weeks postdischarge, recruited participants will wear an ambulatory blood pressure monitor for 24 hours. Mean daytime ambulatory blood pressure will be calculated to assess for the presence or absence of hypertension. Diagnostic performance of in-hospital blood pressure will be assessed by constructing receiver operator characteristic curves from participants' in-hospital mean systolic and mean diastolic blood pressure (index test) versus diagnosis of hypertension determined by mean daytime ambulatory blood pressure (reference test).

ETHICS AND DISSEMINATION

Ethical approval has been provided by the National Health Service Health Research Authority South Central-Oxford B Research Ethics Committee (19/SC/0026). Findings will be disseminated through national and international conferences, peer-reviewed journals and social media.

Post-intervention qualitative assessment of mobile health technology to manage hypertension among Ghanaian stroke survivors

Stroke is a leading cause of death in Africa and a key modifiable risk factor for the index and recurrent stroke is through the adequate management of blood pressure. Recent guidelines encourage management beyond clinic settings, yet implementation of these guidelines can be challenging, especially in resource constrained regions, such as in Sub-Saharan Africa. Mobile health technology may offer an innovative and cost-effective approach to improve BP monitoring and facilitate adherence to antihypertensive medications. Stroke survivors (n = 16) and their caregivers (n = 8) who participated in a 3-month feasibility study were invited to share post-intervention insights via focus groups (n = 3). Clinician (n = 7) input on intervention delivery and clinical impressions was also obtained via a separate focus group (n = 1). Four major themes emerged highlighting the ability to self-monitor, the use of technology as an interventional tool, training and support, and post-intervention adherence. Overwhelming receptivity toward home blood pressure monitoring and the use of mobile health (mHealth) was noted. Feedback indicated benefits in having access to equipment and that message prompts facilitated adherence. Post-intervention adherence declined following study intervention, indicating a need for increased exposure to facilitate long-term behavioral change, although participants conveyed a heightened awareness of the importance of BP monitoring and lifestyle changes needed.

[Position statement on ambulatory blood pressure monitoring (ABPM) by the Spanish Society of Hypertension (2019)]

Conventional blood pressure (BP) measurement in clinical practice is the most used procedure for the diagnosis and treatment of hypertension (HT), but is subject to considerable inaccuracies due to, on the one hand, the inherent variability of the BP itself and, on the other hand biases arising from the measurement technique and conditions, Some studies have demonstrated the prognosis superiority in the development of cardiovascular disease using ambulatory blood pressure monitoring (ABPM). It can also detect "white coat" hypertension, avoiding over-diagnosis and over-treatment in many cases, as well detecting of masked hypertension, avoiding under-detection and under-treatment. ABPM is recognised in the diagnosis and management of HT in most of international guidelines on hypertension. The present document, taking the recommendations of the European Society of Hypertension as a reference, aims to review the more recent evidence on ABPM, and to serve as guidelines for health professionals in their clinical practice and to encourage ABPM use in the diagnosis and follow-up of hypertensive subjects. Requirements, procedure, and clinical indications for using ABPM are provided. An analysis is also made of the main contributions of ABPM in the diagnosis of "white coat" and masked HT phenotypes, short term BP variability patterns, its use in high risk and resistant hypertension, as well as its the role in special population groups like children, pregnancy and elderly. Finally, some aspects about the current situation of the Spanish ABPM Registry and future perspectives in research and potential ABPM generalisation in clinical practice are also discussed.

Clinical practice guideline monitoring children and young people with, or at risk of developing autosomal dominant polycystic kidney disease (ADPKD)

Autosomal Dominant Polycystic Kidney Disease (ADPKD) is thought to affect about 1 in 1000 people in the UK. ADPKD causes a progressive decline in kidney function, with kidney failure tending to occur in middle age. Children and young people with ADPKD may not have any symptoms. However they may have high blood pressure, which may accelerate progression to later stages of chronic kidney disease.There is uncertainty and variation in how health professionals manage children and young people with confirmed or a family history of ADPKD, because of a lack of evidence. For example, health professionals may be unsure about when to test children's blood pressure and how often to monitor it in the hospital clinic or at the GP. They may have different approaches in recommending scanning or genetic testing for ADPKD in childhood, with some recommending waiting until the young person is mature enough to make this decision his or herself.This guideline is intended to help families affected by ADPKD by making sure that: health professionals with specialist knowledge in ADPKD offer you information on inheritance and potential benefits and harms of testing for ADPKD. the decision to test and the method of testing for ADPKD in children and young people is shared between you or your family and the health professionals blood pressure assessment is undertaken regularly in children and young people at risk of developing ADPKD.

Long-term Outcomes of the Effects of Home Blood Pressure Telemonitoring and Pharmacist Management on Blood Pressure Among Adults With Uncontrolled Hypertension: Follow-up of a Cluster Randomized Clinical Trial

IMPORTANCE

Hypertension is a leading cause of cardiovascular disease. The results were previously reported of a trial of home blood pressure (BP) telemonitoring and pharmacist management intervention in which the interventions stopped after 12 months. There were significantly greater reductions in systolic BP (SBP) in the intervention group than in the usual care group at 6, 12, and 18 months (-10.7, -9.7, and -6.6 mm Hg, respectively).

OBJECTIVES

To examine the durability of the intervention effect on BP through 54 months of follow-up and to compare BP measurements performed in the research clinic and in routine clinical care.

DESIGN, SETTING, AND PARTICIPANTS

Follow-up of a cluster randomized clinical trial among 16 primary care clinics and 450 patients with uncontrolled hypertension in a large health system from March 2009 to November 2015.

INTERVENTIONS

A home BP telemonitoring intervention with pharmacist management or usual care.

MAIN OUTCOMES AND MEASURES

Change from baseline to 54 months in SBP and diastolic BP (DBP) measured as the mean of 3 measurements obtained at each research clinic visit.

RESULTS

Among 450 patients, 228 (mean [SD] age, 62.0 [11.7] years; 54.8% male) were randomized to the telemonitoring intervention and 222 (mean [SD] age, 60.2 [12.2] years; 55.9% male) to usual care. Research clinic BP measurements were obtained from 326 of 450 (72.4%) study patients at the 54-month follow-up visit, including 162 (mean [SD] age, 62.0 [11.1] years; 54.9% male) randomized to the telemonitoring intervention and 164 (mean [SD] age, 60.0 [11.2] years; 57.3% male) to usual care. Routine clinical care BP measurements were obtained from 439 of 450 (97.6%) study patients at 6248 visits during the follow-up period. Based on research clinic measurements, baseline mean SBP was 148 mm Hg in both groups. In the intervention group, mean SBP at 6-, 12-, 18-, and 54-month follow-up was 126.7, 125.7, 126.9, and 130.6 mm Hg, respectively. In the usual care group, mean SBP at 6-, 12-, 18-, and 54-month follow-up was 136.9, 134.8, 133.0, and 132.6 mm Hg, respectively. The differential reduction by study group in SBP from baseline to 54 months was -2.5 mm Hg (95% CI, -6.3 to 1.2 mm Hg; P = .18). The DBP followed a similar pattern, with a differential reduction by study group from baseline to 54 months of -1.0 mm Hg (95% CI, -3.2 to 1.2 mm Hg; P = .37). The SBP and DBP results from routine clinical measurements suggested significantly lower BP in the intervention group for up to 24 months.

CONCLUSIONS AND RELEVANCE

This intensive intervention had sustained effects for up to 24 months (12 months after the intervention ended). Long-term maintenance of BP control is likely to require continued monitoring and resumption of the intervention if BP increases.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT00781365.

Clinical accuracy of the Omron M3 Comfort® and the Omron Evolv® for self-blood pressure measurements in pregnancy and pre-eclampsia - validation according to the Universal Standard Protocol

BACKGROUND

Electronic devices for blood pressure (BP) measurements need to go through independent clinical validation as recommended by different authorities, both in general and in special populations such as pregnancy.

OBJECTIVE

To evaluate the accuracy of the Omron Evolv® (HEM-7600T-E) and the Omron M3 Comfort® (HEM-7134-E) devices in pregnancy and pre-eclampsia according to the Universal Standard Validation Protocol.

METHODS

Both devices, the Evolv and the M3 Comfort, measure BP at the brachial level using the oscillometric method. The study was performed according to the recently published protocol, the so-called "modified Advancement of Medical Instrumentation (AAMI)/British Hypertension Society (BHS)/European Society of Hypertension (ESH) protocol" or the "Universal Standard Protocol." Validation of each device included 45 pregnant women in the second and third gestational trimester of whom 15 had pre-eclampsia, 15 had gestational hypertension and 15 were normotensives. BP differences between the observer and the device BP values were classified into three categories (≤5, ≤10, and ≤15 mmHg) and the mean BP differences (test vs reference) and its SD were calculated.

RESULTS

Both devices, the Evolv and the M3 Comfort, achieved a grade A/A in both pregnancy and pre-eclampsia. The mean difference (SD) between the mercury standard and the device BP values in pregnancy were: 1) for the Evolv of -0.7±2.3 mmHg for systolic blood pressure (SBP) and -0.1±1.8 mmHg for diastolic blood pressure (DBP); 2) for the M3 Comfort of -1.6±2.8 mmHg for SBP and -0.1±2.3 mmHg for DBP.

CONCLUSION

Both devices, the Evolv and the M3 Comfort, achieved a grade A/A for both SBP and DBP and fulfill the validation protocol criteria in pregnancy and pre-eclampsia. Consequently, these two devices can be recommended for home BP measurements in this specific population.

Rationale and design for the Asia BP@Home study on home blood pressure control status in 12 Asian countries and regions

Home blood pressure (BP) monitoring is endorsed in multiple guidelines as a valuable adjunct to office BP measurements for the diagnosis and management of hypertension. In many countries throughout Asia, physicians are yet to appreciate the significant contribution of BP variability to cardiovascular events. Furthermore, data from Japanese cohort studies have shown that there is a strong association between morning BP surge and cardiovascular events, suggesting that Asians in general may benefit from more effective control of morning BP. We designed the Asia BP@Home study to investigate the distribution of hypertension subtypes, including white-coat hypertension, masked morning hypertension, and well-controlled and uncontrolled hypertension. The study will also investigate the determinants of home BP control status evaluated by the same validated home BP monitoring device and the same standardized method of home BP measurement among 1600 or more medicated patients with hypertension from 12 countries/regions across Asia.

Insights in Public Health: Ambulatory Blood Pressure Monitoring: Underuse in Clinical Practice in Hawai'i

Hypertension is one of the leading causes of death and disability worldwide. Blood pressure reduction and control are associated with reduced risk of stroke and cardiovascular disease. To achieve optimal reduction and control, reliable and valid methods for blood pressure measurement are needed. Office based measurements can result in 'white coat' hypertension, which is when a patient's blood pressure in a clinical setting is higher than in other settings, or 'masked' hypertension, which occurs when a patient's blood pressure is normal in a clinical setting, but elevated outside the clinical setting. In 2015, the US Preventative Services Task Force recommended Ambulatory Blood Pressure Monitoring (ABPM) as the "best method" for measuring blood pressure, endorsing its use both for confirming the diagnosis of hypertension and for excluding 'white coat' hypertension. ABPM is a safe, painless and non-invasive test wherein patients wear a small digital blood pressure machine attached to a belt around their body and connected to a cuff around their upper arm that enables multiple automated blood pressure measurements at designated intervals (typically every 15 to 30 minutes) throughout the day and night for a specified period (eg, 24 hours). Patients can go about their typical daily activities wearing the device as much as possible, except when they are bathing, showering, or engaging in heavy exercise. Given the importance of blood pressure monitoring and control to population public health, this article provides details on the relevance and challenges of blood pressure measurement broadly then describes ABPM generally and specifically in the Hawai'i context.

Comparison of ambulatory blood pressure and clinic blood pressure in relation to cardiovascular diseases in diabetic patients

The aim of this study was to evaluate prognostic values of ambulatory blood pressure (ABP) and clinic blood pressure (CBP) in diabetic patients with hypertension. A total of 450 diabetic hypertensive patients without established cardiovascular diseases were enrolled and 416 patients who had finished 12months' follow-up were included in final analysis. Baseline data were collected and Cox proportional hazards regression analysis was used to evaluate prognostic value of ABP and CBP. Compared to those without study endpoints (n = 370), those experienced study endpoints (n = 46) were more elderly and more likely to be male, and had longer hypertension duration (7.0 ± 3.0 years vs. 6.4 ± 2.1 years, P < .05). No significant between-group differences in CBP indices were observed. However, those with study endpoints had significantly higher 24-hour systolic BP (SBP) (134 ± 10 mmHg vs. 128 ± 7 mmHg), nighttime SBP (130 ± 7 mmHg vs. 120 ± 5 mmHg), night/day SBP ratio (0.97 ± 0.09 vs. 0.94 ± 0.08), higher proportion of non-dipping BP pattern (39.1% vs. 31.4%) and higher 24-hour SBP variability. After extensively adjusted for traditional risk factors, nondipping BP pattern and 24-hourSBP, only 24-hour SBP and nighttime SBP remained independently related with cardiovascular outcomes, with hazard ratios and associated 95% confidence interval as 1.53 (1.28-2.03) and 1.50 (1.26-1.89), respectively. Although no independent relationship between BP pattern and cardiovascular outcomes was observed. In summary, in diabetic hypertensive patients without established cardiovascular diseases, baseline 24-hour SBP and nighttime SBP are useful markers for predicting short-term cardiovascular outcomes.

An Assessment of the Accuracy of Home Blood Pressure Monitors When Used in Device Owners

OBJECTIVE

To examine the accuracy of home blood pressure (BP) devices, on their owners, compared to auscultatory reference standard BP measurements.

METHODS

Eighty-five consecutive consenting subjects ≥18 years of age, who owned an oscillometric home BP device (wrist or upper-arm device), with BP levels between 80-220/50-120 mm Hg, and with arm circumferences between 25-43 cm were studied. Pregnancy and atrial fibrillation were exclusion criteria. Device measurements from each subject's home BP device were compared to simultaneous 2-observer auscultation using a mercury sphygmomanometer. Between-group mean comparisons were conducted using paired t-tests. The proportion of patients with device-to-auscultatory differences of ≥5, 10, and 15 mm Hg were tabulated and predictors of systolic and diastolic BP differences were identified using linear regression.

RESULTS

Mean age was 66.4 ± 11.0 years, mean arm circumference was 32.7 ± 3.7 cm, 54% were female and 78% had hypertension. Mean BPs were 125.7 ± 14.0/73.9 ± 10.4 mm Hg for home BP devices vs. 129.0 ± 14.7/72.9 ± 9.3 for auscultation (difference of -3.3 ± 7.3/0.9 ± 6.1; P values <0.0001 for systolic and 0.17 for diastolic). The proportion of devices with systolic or diastolic BP differences from auscultation of ≥5, 10, and 15 mm Hg was 69%, 29%, and 7%, respectively. Increasing arm circumference was a statistically significant predictor of higher systolic (parameter estimate 0.61 per cm increase; P value 0.004) and diastolic (0.38; 0.03) BP.

CONCLUSIONS

Although mean differences from 2-observer auscultation were acceptable, when tested on their owners, most home BP devices were not accurate to within 5 mm Hg. Ensuring acceptable accuracy of the device-owner pairing should be prioritized.

Thresholds for Ambulatory Blood Pressure Among African Americans in the Jackson Heart Study

BACKGROUND

Ambulatory blood pressure (BP) monitoring is the reference standard for out-of-clinic BP measurement. Thresholds for identifying ambulatory hypertension (daytime systolic BP [SBP]/diastolic BP [DBP] ≥135/85 mm Hg, 24-hour SBP/DBP ≥130/80 mm Hg, and nighttime SBP/DBP ≥120/70 mm Hg) have been derived from European, Asian, and South American populations. We determined BP thresholds for ambulatory hypertension in a US population-based sample of African American adults.

METHODS

We analyzed data from the Jackson Heart Study, a population-based cohort study comprised exclusively of African American adults (n=5306). Analyses were restricted to 1016 participants who completed ambulatory BP monitoring at baseline in 2000 to 2004. Mean SBP and DBP levels were calculated for daytime (10:00 am-8:00 pm), 24-hour (all available readings), and nighttime (midnight-6:00 am) periods, separately. Daytime, 24-hour, and nighttime BP thresholds for ambulatory hypertension were identified using regression- and outcome-derived approaches. The composite of a cardiovascular disease or an all-cause mortality event was used in the outcome-derived approach. For this latter approach, BP thresholds were identified only for SBP because clinic DBP was not associated with the outcome. Analyses were stratified by antihypertensive medication use.

RESULTS

Among participants not taking antihypertensive medication, the regression-derived thresholds for daytime, 24-hour, and nighttime SBP/DBP corresponding to clinic SBP/DBP of 140/90 mm Hg were 134/85 mm Hg, 130/81 mm Hg, and 123/73 mm Hg, respectively. The outcome-derived thresholds for daytime, 24-hour, and nighttime SBP corresponding to a clinic SBP ≥140 mm Hg were 138 mm Hg, 134 mm Hg, and 129 mm Hg, respectively. Among participants taking antihypertensive medication, the regression-derived thresholds for daytime, 24-hour, and nighttime SBP/DBP corresponding to clinic SBP/DBP of 140/90 mm Hg were 135/85 mm Hg, 133/82 mm Hg, and 128/76 mm Hg, respectively. The corresponding outcome-derived thresholds for daytime, 24-hour, and nighttime SBP were 140 mm Hg, 137 mm Hg, and 133 mm Hg, respectively, among those taking antihypertensive medication.

CONCLUSIONS

On the basis of the outcome-derived approach for SBP and regression-derived approach for DBP, the following definitions for daytime, 24-hour, and nighttime hypertension corresponding to clinic SBP/DBP ≥140/90 mm Hg are proposed for African American adults: daytime SBP/DBP ≥140/85 mm Hg, 24-hour SBP/DBP ≥135/80 mm Hg, and nighttime SBP/DBP ≥130/75 mm Hg, respectively.

Diagnostic performance of an automatic blood pressure measurement device, Microlife WatchBP Home A, for atrial fibrillation screening in a real-world primary care setting

OBJECTIVE

To evaluate the diagnostic performance of a UK National Institute for Health and Care Excellence-recommended automatic oscillometric blood pressure (BP) measurement device incorporated with an atrial fibrillation (AF) detection algorithm (Microlife WatchBP Home A) for real-world AF screening in a primary healthcare setting.

SETTING

Primary healthcare setting in Hong Kong.

INTERVENTIONS

This was a prospective AF screening study carried out between 1 September 2014 and 14 January 2015. The Microlife device was evaluated for AF detection and compared with a reference standard of lead-I ECG.

PRIMARY OUTCOME MEASURES

Diagnostic performance of Microlife for AF detection.

RESULTS

5969 patients (mean age: 67.2±11.0 years; 53.9% female) were recruited. The mean CHA₂DS₂-VASc ( C : congestive heart failure [1 point]; H : hypertension [1 point]; A₂ : age 65-74 years [1 point] and age ≥75 years [2 points]; D : diabetes mellitus [1 point]; S : prior stroke or transient ischemic attack [2 points]; VA : vascular disease [1 point]; and Sc : sex category [female] [1 point])score was 2.8±1.3. AF was diagnosed in 72 patients (1.21%) and confirmed by a 12-lead ECG. The Microlife device correctly identified AF in 58 patients and produced 79 false-positives. The corresponding sensitivity and specificity for AF detection were 80.6% (95% CI 69.5 to 88.9) and 98.7% (95% CI 98.3 to 98.9), respectively. Among patients with a false-positive by the Microlife device, 30.4% had sinus rhythm, 35.4% had sinus arrhythmia and 29.1% exhibited premature atrial complexes. With the low prevalence of AF in this population, the positive and negative predictive values of Microlife device for AF detection were 42.4% (95% CI 34.0 to 51.2) and 99.8% (95% CI 99.6 to 99.9), respectively. The overall diagnostic performance of Microlife device to detect AF as determined by area under the curves was 0.90 (95% CI 0.89 to 0.90).

CONCLUSIONS

In the primary care setting, Microlife WatchBP Home was an effective means to screen for AF, with a reasonable sensitivity of 80.6% and a high negative predictive value of 99.8%, in addition to its routine function of BP measurement. In a younger patient population aged <65 years with a lower prevalence of AF, Microlife WatchBP Home A demonstrated a similar diagnostic accuracy.

Which dialysis unit blood pressure is the most accurate for predicting home blood pressure in patients undergoing hemodialysis?

BACKGROUND/AIMS

We investigated which dialysis unit blood pressure (BP) is the most useful for predicting home BP in patients undergoing hemodialysis (HD).

METHODS

Patients undergoing HD who had been treated > 3 months were included in this study. Exclusion criteria were hospitalized patients with acute illness and changes in dry weight and anti-hypertensive drugs 2 weeks before the study. We used the dialysis unit BP recording data, such as pre-HD, intra-HD, post-HD, mean pre-HD, and post-HD (pre-post-HD), mean pre-HD, intra-HD, and post-HD (pre-intra-post-HD) BP. Home BP (the same period of dialysis unit BP) was monitored as a reference method during 2 weeks using the same automatic oscillometric device. Patients were asked to record their BP three times daily (wake up, between noon and 6:00 PM, and at bedtime).

RESULTS

Significant differences were detected between home systolic blood pressure (SBP) and pre-HD, post-HD, and intra-HD SBP (p = 0.003, p = 0.001, p = 0.016, respectively). In contrast, no differences were observed between home SBP and pre-intra-post-HD and pre-post-HD SBP (p = 0.235, p = 0.307, respectively). Areas under the receiver operating characteristic curve for pre-intra-post-HD and prepost-HD SBP with 2-week home BP as the reference standard were 0.812 and 0.801, respectively.

CONCLUSIONS

These results suggest that pre-intra-post-HD and pre-post-HD SBP had similar accuracy for predicting mean 2-week home SBP in HD patients. Therefore, pre-intra-post-HD and pre-post-HD SBP should be useful for predicting home SBP in HD patients if ambulatory or home BP measurements are unavailable.

PURLs: Monitoring home BP readings just got easier

This novel method of identifying patients with uncontrolled hypertension correlates well with ambulatory BP monitoring.

Cloud-based BP system integrated with CPOE improves self-management of the hypertensive patients: A randomized controlled trial

BACKGROUND

Less than 50% of patients with hypertensive disease manage to maintain their blood pressure (BP) within normal levels.

OBJECTIVE

The aim of this study is to evaluate whether cloud BP system integrated with computerized physician order entry (CPOE) can improve BP management as compared with traditional care.

METHODS

A randomized controlled trial done on a random sample of 382 adults recruited from 786 patients who had been diagnosed with hypertension and receiving treatment for hypertension in two district hospitals in the north of Taiwan. Physicians had access to cloud BP data from CPOE. Neither patients nor physicians were blinded to group assignment. The study was conducted over a period of seven months.

RESULTS

At baseline, the enrollees were 50% male with a mean (SD) age of 58.18 (10.83) years. The mean sitting BP of both arms was no different. The proportion of patients with BP control at two, four and six months was significantly greater in the intervention group than in the control group. The average capture rates of blood pressure in the intervention group were also significantly higher than the control group in all three check-points.

CONCLUSIONS

Cloud-based BP system integrated with CPOE at the point of care achieved better BP control compared to traditional care. This system does not require any technical skills and is therefore suitable for every age group. The praise and assurance to the patients from the physicians after reviewing the Cloud BP records positively reinforced both BP measuring and medication adherence behaviors.

How Accurate Are Home Blood Pressure Devices in Use? A Cross-Sectional Study

Background

Out of office blood pressure measurements, using either home monitors or 24 hour ambulatory monitoring, is widely recommended for management of hypertension. Though validation protocols, meant to be used by manufacturers, exist for blood pressure monitors, there is scant data in the literature about the accuracy of home blood pressure monitors in actual clinical practice. We performed a chart review in the blood pressure assessment clinic at a tertiary care centre.

Methods

We assessed the accuracy of home blood pressure monitors used by patients seen in the nephrology clinic in Ottawa between the years 2011 to 2014. We recorded patient demographics and clinical data, including the blood pressure measurements, arm circumference and the manufacturer of the home blood pressure monitor. The average of BP measurements performed with the home blood pressure monitor, were compared to those with the mercury sphygmomanometer. We defined accuracy based on a difference of 5 mm Hg in the blood pressure values between the home monitor and mercury sphygmomanometer readings. The two methods were compared using a Bland-Altman plot and a student’s t-test.

Results

The study included 210 patients. The mean age of the study population was 67 years and 61% was men. The average mid-arm circumference was 32.2 cms. 30% and 32% of the home BP monitors reported a mean systolic and diastolic BP values, respectively, different from the mercury measurements by 5 mm Hg or more. There was no significant difference between the monitors that were accurate versus those that were not when grouped according to the patient characteristics, cuff size or the brand of the home monitor.

Conclusions

An important proportion of home blood pressure monitors used by patients seen in our nephrology clinic were inaccurate. A re-validation of the accuracy and safety of the devices already in use is prudent before relying on these measurements for clinical decisions.

How to measure home blood pressure: Recommendations for healthcare professionals and patients

BACKGROUND

Home blood pressure (BP) monitoring is the self-measurement of BP in the home environment. It is complementary to 24-hour ambulatory BP, for better diagnosis and management of patients with high BP. Home BP monitoring is in widespread use, but variation in monitoring protocols could lead to inaccurate assessment of BP.

OBJECTIVE

The aim of this article is to provide a practical guide (with resources) for patients and doctors on how to measure home BP according to a standardised, evidence-based protocol.

DISCUSSION

Home BP should be measured using a validated, automatic BP device (preferably with memory storage), using an appropriately sized upper arm cuff. Measurements should be taken after five minutes of seated rest and before medication, food or vigorous exercise. BP should be recorded for seven days (five days minimum) in the morning and evening (two readings each). Overall, home BP is the average systolic and diastolic BP over seven days (excluding the first day); an average of ≥135/85 mmHg is indicative of hypertension.

A critical appraisal of the guidelines from France, the UK, Europe and the USA for the management of hypertension in adults

Hypertension is the leading cause of death in developed countries; its management is the subject of guidelines that are regularly reviewed and updated. However, the guidelines from France, the UK, Europe and the USA differ. Some recommendations are graded, whereas others are not. All recommendations emphasize the role of alternative methods for clinical measurement of blood pressure, such as ambulatory blood pressure measurement (ABPM) or self-measurement. The UK guideline recommends that the diagnosis of hypertension should be established by ABPM. The USA guideline recommends a target of ≤ 150/90 mmHg for patients aged >60 years. The French guideline recommends that the target blood pressure remains at <140/90 mmHg, with <150 mmHg for patients aged >80 years. Systolic blood pressure between 130 and 139 mmHg and diastolic blood pressure <90 mmHg are recommended for diabetic patients and those with chronic kidney disease. The French Society of Hypertension (SFHTA) guideline is unique in recommending a dedicated consultation to announce the diagnosis to the patient. In the French and European guidelines, diuretics, beta-blockers, calcium antagonists, angiotensin-converting enzyme (ACE) inhibitors and angiotensin II type 1 receptor blockers (ARBs) remain indicated as first-line therapy for hypertension; if the target blood pressure is not achieved, they recommend combining two active substances. The UK guideline recommends ACE inhibitors or ARBs as first-line therapy for patients aged <55 years; calcium antagonists are advised for patients aged >55 years and for black patients. The USA guideline advises treating non-black patients, including those with diabetes, with thiazides, calcium antagonists, ACE inhibitors or ARBs; for black patients, including those with diabetes, it recommends thiazide and calcium antagonists.

Oscillometric casual blood pressure normative standards for Swedish children using ABPM to exclude casual hypertension

BACKGROUND

Casual blood pressure (CBP) is considered a reliable proxy for cardiovascular health. Although the auscultatory technique is the reference standard method for measuring CBP, oscillometric devices are increasingly being used in children. We sought to establish oscillometric CBP normative standards for Swedish children.

METHODS

Cross-sectional oscillometric CBP readings were obtained by the Welch Allyn Spot Vital Signs 420 monitor and measured according to the International Guidelines' recommendations. Participants with elevated oscillometric CBP levels underwent verification by the auscultatory method. Ambulatory blood pressure monitoring (ABPM) was used to exclude casual hypertension. Data on 1,470 (772 males) apparently healthy Swedish schoolchildren aged 6-16 years were analyzed and sex-specific reference charts normalized to age or height were constructed.

RESULTS

Systolic and diastolic CBP values were significantly higher with age, height, height standard deviation score (SDS), body mass index (BMI), and BMI SDS. Gender differences for systolic CBP were present starting from age of 15 years and revealed significantly higher values in boys than in girls, whereas for diastolic CBP, the differences were apparent at the age of 12 years, with higher values in girls. Increased BMI and BMI SDS were positively associated with CBP levels. Positive parental history of hypertension turned out to be a risk factor for higher systolic and diastolic CBP across all ages.

CONCLUSIONS

Our normative standard for CBP can be used for blood pressure screening and control programs in Swedish children. The use of ABPM should be considered to confirm the diagnosis of casual hypertension.

Relevance to home blood pressure monitoring protocol of blood pressure measurements taken before first- morning micturition and in the afternoon

BACKGROUND

The importance of measuring blood pressure before morning micturition and in the afternoon, while working, is yet to be established in relation to the accuracy of home blood pressure monitoring (HBPM).

OBJECTIVE

To compare two HBPM protocols, considering 24-hour ambulatory blood pressure monitoring (wakefulness ABPM) as gold-standard and measurements taken before morning micturition (BM) and in the afternoon (AM), for the best diagnosis of systemic arterial hypertension (SAH), and their association with prognostic markers.

METHODS

After undergoing 24-hour wakefulness ABPM, 158 participants (84 women) were randomized for 3- or 5-day HBPM. Two variations of the 3-day protocol were considered: with measurements taken before morning micturition and in the afternoon (BM+AM); and with post-morning-micturition and evening measurements (PM+EM). All patients underwent echocardiography (for left ventricular hypertrophy - LVH) and urinary albumin measurement (for microalbuminuria - MAU).

RESULT

Kappa statistic for the diagnosis of SAH between wakefulness-ABPM and standard 3-day HBPM, 3-day HBPM (BM+AM) and (PM+EM), and 5-day HBPM were 0.660, 0.638, 0.348 and 0.387, respectively. The values of sensitivity of (BM+AM) versus (PM+EM) were 82.6% × 71%, respectively, and of specificity, 84.8% × 74%, respectively. The positive and negative predictive values were 69.1% × 40% and 92.2% × 91.2%, respectively. The comparisons of intraclass correlations for the diagnosis of LVH and MAU between (BM+AM) and (PM+EM) were 0.782 × 0.474 and 0.511 × 0.276, respectively.

CONCLUSIONS

The 3 day-HBPM protocol including measurements taken before morning micturition and during work in the afternoon showed the best agreement with SAH diagnosis and the best association with prognostic markers.

[Importance of standardized stepwise screening in patients with resistant hypertension]

Resistant hypertension (RH) is a condition that confers a high cardiovascular risk to the patient due to both persistent blood pressure elevation and the high prevalence of comorbidities and organ damage. Hypertension is defined as resistant (RH) to treatment when a therapeutic strategy that includes appropriate lifestyle measures plus a diuretic and two other antihypertensive drugs belonging to different classes at adequate doses fails to lower blood pressure (BP) values to < 140 and 90 mm Hg, respectively. Prior to diagnosing a patient as having RH, it is important to document adherence and exclude white-coat hypertension, inaccurate measurement of BP, and secondary causes. Ambulatory BP monitoring (ABPM) has become an important tool in the diagnosis and follow-up of hypertensive patient, and it is even more important in the evaluation of those with resistant RH. Among patients with RH, it is very important to select patients with standardized stepwise screening: ABPM of resistant hypertensives has a circadian profile with a high proportion of nondipping. The possible reasons for the absence of dipping are sleep disturbance, obstructive sleep apnea, obesity, high salt intake in salt-sensitive subjects, orthostatic hypotension, autonomic dysfunction, chronic kidney disease, diabetic neuropathy, and old age. It seems reasonable to routinely use ABPM in the initial evaluation of all resistant hypertensive patients. In a significant number of these patients, ABPM will also be an essential tool in follow-up, especially regarding the possible effects of all therapeutic maneuvers that are devoted to bringing BP into the target ranges. The potential success of other therapeutic options such as renal denervation depends on the ability to select patients most likely to benefit.

Evaluation of a chronic disease management system for the treatment and management of diabetes in primary health care practices in Ontario: an observational study

BACKGROUND

Computerized chronic disease management systems (CDMSs), when aligned with clinical practice guidelines, have the potential to effectively impact diabetes care.

OBJECTIVE

The objective was to measure the difference between optimal diabetes care and actual diabetes care before and after the introduction of a computerized CDMS.

METHODS

This 1-year, prospective, observational, pre/post study evaluated the use of a CDMS with a diabetes patient registry and tracker in family practices using patient enrolment models. Aggregate practice-level data from all rostered diabetes patients were analyzed. The primary outcome measure was the change in proportion of patients with up-to-date "ABC" monitoring frequency (i.e., hemoglobin A1c, blood pressure, and cholesterol). Changes in the frequency of other practice care and treatment elements (e.g., retinopathy screening) were also determined. Usability and satisfaction with the CDMS were measured.

RESULTS

Nine sites, 38 health care providers, and 2,320 diabetes patients were included. The proportion of patients with up-to-date ABC (12%), hemoglobin A1c (45%), and cholesterol (38%) monitoring did not change over the duration of the study. The proportion of patients with up-to-date blood pressure monitoring improved, from 16% to 20%. Data on foot examinations, retinopathy screening, use of angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers, and documentation of self-management goals were not available or not up to date at baseline for 98% of patients. By the end of the study, attitudes of health care providers were more negative on the Training, Usefulness, Daily Practice, and Support from the Service Provider domains of the CDMS, but more positive on the Learning, Using, Practice Planning, CDMS, and Satisfaction domains.

LIMITATIONS

Few practitioners used the CDMS, so it was difficult to draw conclusions about its efficacy. Simply giving health care providers a potentially useful technology will not ensure its use.

CONCLUSIONS

This real-world evaluation of a web-based CDMS for diabetes failed to impact physician practice due to limited use of the system.

PLAIN LANGUAGE SUMMARY

Patients and health care providers need timely access to information to ensure proper diabetes care. This study looked at whether a computer-based system at the doctor's office could improve diabetes management. However, few clinics and health care providers used the system, so no improvement in diabetes care was seen.

[Ambulatory blood pressure monitoring: essential for diagnosing and treating hypertension?]

According to recent international guidelines, 24-h ambulatory blood pressure monitoring plays an important role in the diagnostic and therapeutic approach of arterial hypertension. Indications of this technique are multiple, concerning both day- and night-time blood pressures. Blood pressures provided by ambulatory monitoring may be used to stratify cardiovascular risk.

[Common errors in blood pressure monitoring]

Monitoring blood pressure is an important diagnostic tool in the management of hypertension. Many patients measure their blood pressure at home. However, the results are only reliable if some rules are observed. These are mainly related to the right choice of devices, execution of the monitoring as well as documentation and assessment of the measurement.

Reproducibility of blood pressure dipping: relation to day-to-day variability in sleep quality

Previous studies of the reproducibility of blood pressure (BP) dipping have yielded inconsistent results. Few have examined factors that may influence day-to-day differences in dipping. Ambulatory BP monitoring was performed on three occasions, approximately 1 week apart, in 115 untreated adult subjects with elevated clinic BPs. The mean ± standard deviation BP dip was 18 ± 7/15 ± 5 mm Hg (sleep/awake BP ratio = 0.87 ± 0.05/0.82 ± 0.06), with a median (interquartile range) day-to-day variation of 5.2 (3.1-8.1)/4.3 (2.8-5.6) mm Hg. There was no decrease in variability with successive measurements. The reproducibility coefficient (5.6 [95% confidence interval, 5.1-6.1] mm Hg) was greater and the intraclass correlation coefficient (0.53 [95% confidence interval, 0.42-0.63]) was smaller for the systolic dip than for 24-hour or awake systolic BPs, suggesting greater day-to-day variability in dipping. Variability in systolic dipping was greater in subjects with higher awake BP, but was not related to age, gender, race, or body mass index. Within individuals, day-to-day variations in dipping were related to variations in the fragmentation index (P < .001), a measure of sleep quality. Although mean 24-hour and awake BPs were relatively stable over repeated monitoring days, our study confirms substantial variability in BP dipping. Day-to-day differences in dipping are related to sleep quality.

Estimate of nocturnal blood pressure and detection of non-dippers based on clinical or ambulatory monitoring in the inpatient setting

BACKGROUND

Ambulatory blood pressure monitoring is regarded as the gold standard for monitoring nocturnal blood pressure (NBP) and is usually performed out of office. Currently, a novel method for monitoring NBP is indispensible in the inpatient setting. The widely used manual BP monitoring procedure has the potential to monitor NBP in the hospital setting. The feasibility and accuracy of manual sphygmomanometer to monitor NBP has not been explored widely.

METHODS

A cross-sectional study was conducted at the cardiology department of a university-affiliated hospital to study patients with mild-to-moderate essential hypertension. One hundred and fifty-five patients were recruited to compare BP derived from a manual device and ambulatory BP monitoring (ABPM). The manual BP measurement was performed six times at 22:00, 02:00, 06:00, 10:00, 14:00 and 18:00 h. The measurements at 22:00, 02:00 and 06:00 h were defined as night-time and the others as daytime. ABPM was programmed to measure at 30-min intervals between measurements.

RESULTS

All-day, daytime and night-time BP did not differ significantly from 24-h ambulatory systolic BP [all-day mean difference -0.52±4.67 mmHg, 95% confidence interval (CI) -1.26 to 0.22, P=0.168; daytime mean difference 0.24±5.45 mmHg, 95% CI -0.62 to 1.11, P=0.580; night-time mean difference 0.30±7.22 mmHg, 95% CI -0.84 to 1.45, P=0.601) rather than diastolic BP. There was a strong correlation between clinical and ambulatory BP for both systolic and diastolic BP. On the basis of ABPM, 101 (65%) patients were classified as non-dippers, compared with 106 (68%) by manual sphygmomanometer (P<0.001).

CONCLUSIONS

Traditional manual sphygmomanometer provides similar daytime and night-time systolic BP measurements in hospital. Moreover, the detection of non-dippers by manual methods is in good agreement with 24-h ABPM. Further studies are required to confirm the clinical relevance of these findings by comparing the association of NBP in the hospital ward assessed by manual monitoring with preclinical organ damage and cardiovascular and cerebrovascular outcomes.

Predictive value of night-time heart rate for cardiovascular events in hypertension. The ABP-International study

BACKGROUND

Data from prospective cohort studies regarding the association between ambulatory heart rate (HR) and cardiovascular events (CVE) are conflicting.

METHODS

To investigate whether ambulatory HR predicts CVE in hypertension, we performed 24-hour ambulatory blood pressure and HR monitoring in 7600 hypertensive patients aged 52 ± 16 years from Italy, U.S.A., Japan, and Australia, included in the 'ABP-International' registry. All were untreated at baseline examination. Standardized hazard ratios for ambulatory HRs were computed, stratifying for cohort, and adjusting for age, gender, blood pressure, smoking, diabetes, serum total cholesterol and serum creatinine.

RESULTS

During a median follow-up of 5.0 years there were 639 fatal and nonfatal CVE. In a multivariable Cox model, night-time HR predicted fatal combined with nonfatal CVE more closely than 24h HR (p=0.007 and =0.03, respectively). Daytime HR and the night:day HR ratio were not associated with CVE (p=0.07 and =0.18, respectively). The hazard ratio of the fatal combined with nonfatal CVE for a 10-beats/min increment of the night-time HR was 1.13 (95% CI, 1.04-1.22). This relationship remained significant when subjects taking beta-blockers during the follow-up (hazard ratio, 1.15; 95% CI, 1.05-1.25) or subjects who had an event within 5 years after enrollment (hazard ratio, 1.23; 95% CI, 1.05-1.45) were excluded from analysis.

CONCLUSIONS

At variance with previous data obtained from general populations, ambulatory HR added to the risk stratification for fatal combined with nonfatal CVE in the hypertensive patients from the ABP-International study. Night-time HR was a better predictor of CVE than daytime HR.