Errors and negative outcomes in home blood pressure monitoring by hypertensive individuals: a scoping review.

Out-of-office blood pressure measurement in children and adolescents

he conventional measurement of blood pressure(BP) in the office or clinic has been the cornerstonefor hypertension management for decades. How-ever, because of the white-coat and the masked hyper-tension phenomena, out-of-office BP monitoring withambulatory or home measurements is often required [1].ExtensiveresearchonambulatoryBPmonitoringhasestab-lished its role as the most accurate tool for hypertensiondiagnosis [1–3].Onthecontrary,despitetheincreasinguseof home BP monitoring by hypertensive patients in thedaily management of their high BP condition, research inthisfield,inparticularwhenconsideringoutcometrials,hasbeen delayed as compared to ambulatory BP monitoring[4,5].

In 2008, the European Society of Hypertension (ESH) [1] and the American Heart Association/American Society of Hypertension [2] published guidelines for home blood pressure (HBP) monitoring and both recommended this method to be widely applied in clinical practice in both the initial diagnostic phase in patients with elevated blood pressure (BP) and also in the long-term follow-up of treated hypertension. These recommendations are based on the evidence about the prognostic value of HBP, its diagnostic ability, its cost-effectiveness, and its good acceptance by hypertensive patients [1,2]. Several studies have assessed the diagnostic value of HBP monitoring by taking ambulatory blood pressure (ABP) monitoring as reference method [1–4]. These studies, however, were quite heterogeneous with regard to their methodology and/or their objectives. First, 11 studies included untreated patients (n = 1866), whereas seven studies included treated hypertensive patients (n = 1059) [3,4]. Moreover, these previous studies included individuals on triple therapy, diabetic patients, patients with renal failure, on hemodialysis, or children and adolescents [3,4]. Second, the diagnostic endpoint was either white-coat hypertension, masked hypertension, sustained hypertension, white-coat effect, masked uncontrolled hypertension, resistant hypertension, or a mixture of these. Third, some studies have taken daytime ABP as reference whereas others focused on 24-h ABP as their reference, and different HBP schedules have been used [3,4]. The results of all these studies, although largely varying according to the diagnostic endpoint, tend to agree in indicating a higher specificity and higher negative predictive value with lower sensitivity and lower positive predictive value for the HBP monitoring method as compared with ABP monitoring. In this issue of the Journal of Hypertension, Kang et al.[5] provide further evidence in this regard, by reporting on the results of a cross-sectional study including data from 1774 patients in China, aimed at comparing the diagnostic accuracy of HBP with that of 24-h ABP monitoring. The results of this study are largely in line with the findings of the above-mentioned previous articles. Moreover, in these previous studies [3,4], there was moderate-to-substantial diagnostic agreement between the two methods (κ statistic 0.40–0.70) [6], a finding that is confirmed by the data by Kang et al.[5] who reported κ-statistic values 0.40–0.66 in untreated and 0.41–0.58 in treated patients when comparing the diagnostic agreement between HBP and ABP monitoring. Although rather confirmatory of previous papers, the study by Kang et al.[5] has several points of strength. First, analyses were performed on a large sample of individuals. Second, both treated and untreated individuals were included. Third, assessments of white-coat, masked and sustained hypertension were included in a single analysis. Fourth, 24 h rather than daytime ABP values were chosen to be taken as reference BP level, which means that night-time ABP was not ignored, in line with recent ESH ABP monitoring guidelines [7,8]. Indeed, the prevalence of masked hypertension was always significantly larger when this condition was assessed by 24-h ABP monitoring, regardless of the antihypertensive treatment status. Fifth, HBP monitoring was implemented according to the recommended schedule by ESH guidelines [1], with 7-day monitoring and duplicate morning and evening measurements. Sixth, assessment of HBP was based on readings exported by the device memory, which thus prevented misreporting; and seventh, implementation and conduction of this study was done in China where there are scarce data comparing HBP with ABP. Overall, the findings by Kang et al.[5] strengthen the importance of current recommendations indicating that presence of masked hypertension should be evaluated by taking into account a whole 24-h monitoring period and not only limiting the assessment to the awake period [7,8]. Somehow surprisingly, however, authors did not find an association between masked hypertension and advanced age, diabetes mellitus, and, more in general, major cardiovascular risk factors, a finding which is in contrast with other population studies [9–11]. Probably, this is related to the fact that cardiovascular risk level was only low to moderate in this study, and the mean age of the population was younger than in the previous articles. An additional explanation of such finding might be that Chinese hypertensive patients may behave differently from Caucasian individuals, and thus cross comparison of data collected in different ethnic groups worldwide could be useful to identify possible differences. The findings on the diagnostic agreement between HBP and ABP monitoring data in the study by Kang et al.[5] are supported by the results of a similar European study, which found a good agreement between HBP and ABP [12]. In fact, in this article, Nasothimiou et al.[12] also separately analyzed untreated and treated patients and focused on the assessment of white-coat, masked, and sustained hypertension, by investigating in a large dataset the diagnostic ability of HBP versus ABP [12]. Comparison of the two studies in Table 1 shows a striking similarity in the results with a high degree of diagnostic agreement between the two methods, ranging from 80 to 90% across all the hypertension phenotypes in both untreated and treated individuals.TABLE 1: Diagnostic agreement between home and ambulatory blood pressure monitoring in two studies that assessed all hypertension phenotypes separately in untreated and treated patientsThe occurrence of some degree of diagnostic disagreement between HBP and ABP is not an unexpected finding, and should be interpreted by taking into account a few important factors. First, the reproducibility of both HBP and ABP, although being clearly superior to that of office BP, is still imperfect, which means that some level of diagnostic disagreement would be expected even when the same BP monitoring method (HBP or ABP) is applied twice [13]. Thus, on such a background, the level of agreement between the two methods observed in the study by Kang et al.[5] as well as in the previous studies [3,4] might be regarded as excellent. Second, any diagnostic disagreement between HBP and ABP does not necessarily mean that ABP is the correct method and HBP is wrong. In fact, a level of disagreement should be expected because, although the two methods have important similarities (given that they both provide multiple measurements in the usual environment of each individual), they also have important differences. ABP is usually monitored only once, although over 24 h and in fully ambulatory conditions, at work, at home, and during sleep, whereas HBP is monitored over several days, weeks, or months, but always in the same environment and posture (seated after a few minutes of rest, at home). Third, because of the above-mentioned methodological differences, HBP and ABP monitoring appear to have a complementary rather than a competitive role in the evaluation of hypertension and provide similar but also different information about the BP profile and behavior. These data are supported by a study in 2051 patients assessed with HBP and ABP monitoring in Italy, which compared white-coat hypertensive patients who had normal HBP and ABP values with those who showed normal values only with one of these out-office BP monitoring methods, and showed that the latter group had higher risk of cardiovascular event and death [14]. An additional and important difference between data obtained in the study by Kang et al.[5] and data obtained in the previous studies is that in both untreated and treated patients of the study by Kang et al.[5], average diastolic HBP was at similar levels with average 24-h diastolic ABP, whereas systolic HBP was by 4–5 mmHg higher than 24-h systolic ABP. The study by Kang et al.[5] represents one of the first large studies assessing the respective diagnostic values of HBP versus ABP in the detection of white-coat and masked hypertension, in either untreated or treated hypertensive patients. This observational study, based on data collected in a large sample of Chinese hypertensive patients referring to hypertension clinics, yields several relevant new pieces of information on the features of white-coat and masked hypertension as assessed by these BP measuring methods. The low sensitivity and high specificity of home BP suggest that this technique may be useful to exclude a diagnosis of masked or white-coat hypertension but not to confirm its presence. This means that, in terms of hypertension management, ABP monitoring stands as the ideal tool to assess BP control, whereas HBP appears to be a complementary technique [1]. As a matter of fact, although ABP allows repeated measurements to be obtained both during awake activities and night sleep, this is not usually the case for HBP. On the contrary, at variance from 24-h ABP monitoring, self-BP measurements at home are collected over successive days, weeks, or months, which makes HBP monitoring a useful approach to BP assessment during long-term follow-up. With HBP monitoring, however, measurements are usually taken only during waking hours, without any possibility to have information also on night-time BP levels. Thus, on the background of the growing awareness on the importance of night-time BP, in the future, the power of HBP for detecting masked or white-coat hypertension should be tested by considering the inclusion of sleep readings. This possibility is currently provided by new devices for HBP monitoring that allow a number of night-time automated HBP measurements to be obtained. Use of these novel diagnostic tools may thus allow to more precisely check the predictive value of HBP vis-à-vis that of ABP, under more similar settings. In conclusion, the study by Kang et al.[5], together with the previous studies assessing the diagnostic ability of HBP monitoring, support the position of the ESH [1] that recommended the wide application of the method as a reliable alternative to ABP monitoring for the detection of the white-coat and masked hypertension phenomena and the confirmation of sustained hypertension both in the initial evaluation of untreated hypertension and also in the long-term follow-up, when assessing the occurrence of an effective BP control. ACKNOWLEDGEMENTS Conflicts of interest There are no conflicts of interest.

Can We Study Hypertension in Patients on Dialysis? Yes We Can

Matchmaking and the Future of Hypertension Management.

New guidelines for the management of hypertension were recently released by the European Society of Hypertension/European Society of Cardiology (the 2018 ESH/ESC guidelines) and the American College of Cardiology/American Heart Association (the 2017 ACC/AHA guidelines).1, 2 These guidelines stress the importance of out-of-office blood pressure (BP) values over that of office BP values. In Japan and other Asian countries, we have highlighted the use of the out-of-office BP-guided management of hypertension.3-5 Ambulatory BP monitoring (ABPM) and home BP monitoring (HBPM) are the two standard measurements of out-of-office BP. Their use can detect masked (uncontrolled) hypertension (normotension in office BP and hypertension in out-of-office BP) in individuals at the highest risk of cardiovascular events.6-8 There are three clinical phenotypes of masked hypertension: morning hypertension, daytime hypertension, and nocturnal hypertension.9 Ambulatory BP monitoring has traditionally been considered the gold standard to detect the risk of high BP throughout the 24-hour day, and its use can detect all three types of masked hypertension. Toward the achievement of the goal of "zero" cardiovascular events, three components are needed for "perfect 24-hour BP control": (a) lowering the 24-hour BP level, (b) maintaining an adequate circadian rhythm, and (c) avoiding excessive BP variability including the morning BP surge.10 All three of these components can be assessed by ABPM. Extremely disrupted patterns of circadian rhythm of nighttime BP and exaggerated morning BP surge such as the riser pattern (higher nighttime BP than daytime BP) and the extreme-dipper pattern (excessive nighttime BP falls) are reported to be associated with cardiovascular risk.11-13 Home BP monitoring is frequently used in clinical practice and to identify masked hypertension defined by self-measured home BP. The use of HBPM can detect the risk of morning hypertension.14-18 The recently developed "nighttime HBPM" automatically obtains and records BP values at fixed intervals while an individual is sleeping, and it can be used as an alternative to ABPM for the assessment of nighttime BP.13 Two additional modalities have been developed to detect the risk of hypertension during sleep (especially in patients with obstructive sleep apnea): (a) "trigger nighttime HBPM" with a hypoxic episode-trigger function and a heart rate-trigger function and (b) beat-by-beat continuous surge BP monitoring.13, 19 Home BP monitoring can thus detect the risk of morning hypertension and that of nocturnal hypertension. However, HBPM would underestimate the risk of daytime hypertension, because HBPM measures an individual's blood pressure in the less stressful resting condition at home. A patient's behavior, surrounding environment, and various triggering factors affect his or her daytime ambulatory BP changes. Masked daytime hypertension (ie, normotension in office BP and hypertension in daytime BP) induced by physical activity or work- or home-related psychological stress can be detected only by ABPM. We recently developed a device that provides information/communication technology (ICT)-based multi-sensor ABPM (IMS-ABPM), which can store all of the waveforms of intra-cuff pressures during oscillometric BP measurement.20 One of the limitations of the original ABPM is the accuracy of "real" daytime BP measurements, because the daytime movement of the ABPM device wearer's upper arm may modify the intra-cuff pressure and produce BP reading artifacts. By excluding the abnormal BP values with abnormal waveforms as artifacts, we can evaluate the "real" daytime BP measurements more accurately. In addition, based on the IMS-ABPM's stored waveforms and its function of detecting an irregular heartbeat (IHB),21 the device can be used for the screening of atrial fibrillation (AF). The IMS-ABPM device is equipped with a thermosensor, a highly sensitive actigraph, and an atmospheric pressure sensor to simultaneously assess the triggers of BP surge (a pressor component of BP variability).20 By determining the association between many subjects' BP measurements and these triggers, new BP sensitivity indexes could be calculated; for example, the slope of the ambulatory BP values against specific triggers such as temperature (thermosensitivity evaluation), physical activity (actisensitivity), atmospheric pressure (atmospheric sensitivity), humidity (humidity sensitivity), and more. Based on these new indicators, we could classify the characteristics of hypertension with excessive BP sensitivity to specific triggers such as thermosensitive hypertension, actisensitive hypertension, atmospheric hypertension, and humidity-sensitive hypertension. These sensitivities might overlap and augment each other. In fact, the actisensitivity of BP (the slope of daytime BP change against physical activity change during a 5-minute period before the BP measurement) is augmented in the cold winter season compared to the warm summer in the same patients.22 This may partly explain the winter increase in the rate of cardiovascular events. The IMS-ABPM device can specifically detect masked daytime hypertension with a physical activity-induced BP surge. As an example: a 72-year-old woman developed B-type aortic dissection during the daytime. Although she had been treated with amlodipine, candesartan, and hydrochlorothiazide, the IMS-ABPM device detected abnormal 24-hour BP profiles during the year prior to the onset of aortic dissection. The riser pattern was detected in the summer (8 months before the onset), and an excessive morning surge was detected in the autumn (4 months before the onset) (Figure 1A). The patient's simultaneously calculated actisensitivity was also disrupted. The actisensitivity was within the normal range in autumn; however, the inverse actisensitivity (physical activity reduced the ambulatory BP) was found in summer (Figure 1B). The disrupted BP regulation against physical activity, which is modified by environmental (eg, seasonal) conditions, might produce the excessive BP surge that triggers cardiovascular events. Based on recent technology developments, it has been suggested that the use of ICT-based devices and a real-time feedback IoT (Internet of Things)-based system could facilitate a novel approach to patient management.22, 23 In the ImPACT program (IMpulsing PAradigm Change through disruptive Technologies program of the Cabinet Office, Government of Japan), we have successfully developed an integrated system that collects both biologic and environmental data, with the hybrid Wi-SUN/Wi-Fi transmission system (Figure 2). Environmental sensors introduced in a patient's home continuously monitor the temperature, humidity, and illumination in different rooms with different conditions throughout 24-hour periods. An ICT-based wrist-type pulse wave monitoring device (wearable monitoring) which we also developed in the ImPACT program continuously monitors the wearer's pulse rate, pulse wave, and activity. With the combination of these biological sensor devices, environmental sensors, and the hybrid Wi-SUN/Wi-Fi transmission system, the environmental determinants of BP surges (ie, the pressor component of BP variability) with different time phases could be used to identify the riskiest places and times at which an individual's maximum BP surge is exaggerated at home throughout the year (Figure 3). Health information technology (HIT) solutions like this are increasingly being recognized as an important component of the advances in health care, and the latest version of the ACC/AHA hypertension guidelines highlight the importance and emerging roles of HIT.1 Using these new technologies, it is hoped that the occurrence of cardiovascular events could be anticipated based on data obtained by these novel approaches to out-of-office patient monitoring, with the ultimate goal of eliminating the occurrence of cardiovascular events in patients with hypertension. Such an approach is referred to as "anticipation medicine" for zero cardiovascular events, within which BP variability is a key biomarker.10, 19, 20, 22 The self-monitoring of blood pressure using HBPM, particularly when combined with telemonitoring, has recently been shown to facilitate the titration of antihypertensive therapy in subjects with poorly controlled hypertension in general practice, without increasing the general practitioner's workload.24, 25 This highlights the potential for ICT-based out-of-office BP measurement solutions in clinical practice. There is a gap between the guideline-initiated general management of hypertension and the individualized optimal management of hypertension. An increase in the number of out-of-office BP measurements could increase the sensitivity and specificity of the average BP-based diagnosis of hypertension (as guideline-based medicine), and this increase in data could also detect the various specific trigger-induced BP surges, that is, diurnal, day-by-day, and seasonal BP surges (as individualized medicine) (Figure 4). The resonance hypothesis holds that the exaggerated pathological surge BP generated by the resonance of different BP surges with different time phases would trigger cardiovascular events.26 The times and places at which the surge BP is generated would be the most risky times/places for an individual's cardiovascular event onset. Even among well-controlled hypertensive patients, the morning BP surge remains significant in the winter.27 Anticipation medicine for cardiovascular diseases—which both anticipates pathological surge BP based on the previous time series of individual BP data and avoids the generation of surge BP—is an ideal future practical direction to take in order to decrease the gap between the guidelines and individualized medicine in the era of ICT-based "real-world" big data analysis and feedback systems. This paper was supported in part by the IMpulsing PAradigm Change through disruptive Technologies (ImPACT) program of the Cabinet Office, Government of Japan. We thank Makoto Kato, Hiroko Masaki, Tomohide Sato, Satoshi Hoshide, Tomoyuki Kabutoya, Kimiyo Saito, and Tomoko Shiga for their support. We also thank Shinobu Ozaki, Yoshiteru Nozoe, Shinichi Takahashi, and Takahiro Fujiwara from A&D Co. for developing IMS-ABPM, wearable wrist pulse monitoring, and the ICT-based data collecting system, and Takeya Shigezumi, Terumi Sata, and Takashi Naiki from Rohm Co. for developing multi-sensors and the real-time and hybrid Wi-SUN/Wi-Fi transmission system. This paper was supported in part by the IMpulsing PAradigm Change through disruptive Technologies (ImPACT) program of the Cabinet Office, Government of Japan. Nobuhiko Yasui is an employee of A&D Co. Other authors report no conflicts of interest to disclose.

The diagnosis and management of hypertension have been based primarily on blood pressure (BP) measurement in the office setting. Higher out-of-office BP is associated with an increased risk of cardiovascular disease, independent of office BP. Home BP monitoring (HBPM) consists of the measurement of BP by a person outside of the office at home and is a validated approach for out-of-office BP measurement. HBPM provides valuable data for diagnosing and managing hypertension. Another validated approach, ambulatory BP monitoring (ABPM), has been considered to be the reference standard of out-of-office BP measurement. However, HBPM offers potential advantages over ABPM including being a better measure of basal BP, wide availability to patients and clinicians, evidence supporting its use for better office BP control, and demonstrated efficacy when using telemonitoring along with HBPM. This state-of-the-art review examines the current state of HBPM and includes discussion of recent hypertension guidelines on HBPM, advantages of using telemonitoring with HBPM, use of self-titration of antihypertensive medication with HBPM, validation of HBPM devices, best practices for conducting HBPM in the clinical setting, how HBPM can be used as an implementation strategy approach to improve BP control in the United States, health equity in HBPM use, and HBPM use among specific populations. Finally, research gaps and future directions of HBPM are reviewed.

Home and ambulatory blood pressure monitoring: when? who?

Ambulatory Blood Pressure Monitoring: Profiles in Chronic Kidney Disease Patients and Utility in Management.

Home blood pressure monitoring in general practice: expectations and concerns

Introduction For practical reasons, blood pressure values measured by physicians or nurses in a medical environment remain the clinical basis of the diagnosis and management of arterial hypertension around the world as recommended by all guidelines [1–4]. Nevertheless, measurements of blood pressure outside the office have gained an increasing popularity over the last decades not only to ascertain the diagnosis of hypertension but also to follow the impact of therapeutic interventions. Out-of-office blood pressure measurements can be obtained either by 24-h ambulatory blood pressure monitoring or by home blood pressure monitoring. As reviewed recently [5], both sets of out-of-office blood pressure offer undeniable advantages when compared to office blood pressure. First, both ambulatory blood pressure and home blood pressure monitoring provide more reliable and reproducible information on blood pressure. Second, blood pressure values obtained by ambulatory blood pressure and home blood pressure monitoring appear to be more closely related to target organ damage than office blood pressure and hence have a greater prognostic relevance than office blood pressure. Third, certain diagnosis such as white coat hypertension and masked hypertension can only be diagnosed using out-of-office blood pressure measurements. Fourth, when used in the clinical follow-up of treated hypertensive patients to evaluate the impact of drug treatment, ambulatory blood pressure monitoring as well as home blood pressure monitoring has the advantage of not being affected by a placebo effect. Finally, evidence has been provided that treatment-induced reduction in 24-h blood pressure may predict better than office blood pressure the regression of end organ damage (particularly the cardiac one) induced by antihypertensive drug. Many of these information have been achieved during the past two decades by a number of studies carried out in different populations around the world, including the Pressioni Arteriose Monitorate E Loro Associazioni (PAMELA) study [6–10]. When should out-office blood pressure be measured? Despite their advantages, ambulatory blood pressure monitoring as well as home blood pressure monitoring is not regarded as a routine procedure that should be applied to all hypertensive patients essentially for economical reasons. However, this issue is debated because the clinical information gathered with these measurements may potentially result in financial savings when applied adequately. The European and American guidelines for the management of hypertension have defined some indications for the use of ambulatory blood pressure monitoring in hypertension [1,2]. These include patients with resistant hypertension, patients with a high variability of office blood pressure, low-risk patients with a high blood pressure, patients with suspected episodes of hypotension, patients with a large discrepancy between office and home blood pressures, and finally patients with special clinical conditions such as pregnancy or sleep apnea syndrome. Outside these indications, the use of ambulatory blood pressure monitoring could be discussed both in terms of feasibility and economics. Theoretically, a measurement of out-of-office blood pressure could be recommended to all new patients with as suspected hypertension to confirm the diagnosis of hypertension and to refine the patient's cardiovascular risk profile. Therefore, ambulatory blood pressure monitoring could be recommended to all high cardiovascular risk patients before starting any treatment and later under therapy to ascertain the adequacy of the control of blood pressure. Ambulatory blood pressure values in diabetic patients In this issue of the Journal of Hypertension, Leitao et al.[11] report the results of a cross-sectional study performed to estimate the daytime ambulatory blood pressure monitoring values corresponding to the target office blood pressure of 130/80 mmHg for diabetic (as defined by the American Diabetes Association) and to assess which diabetic patients may actually benefit from ambulatory blood pressure monitoring. They included 554 patients in this analysis. Regression analyses were performed to analyze the ambulatory blood pressure monitoring values corresponding to office blood pressure and receiver operating characteristics (ROC) curves were used to assess the sensitivity and specificity of office blood pressure in diagnosing daytime ambulatory blood pressure monitoring hypertension. According to their regression equations, the daytime ambulatory blood pressure monitoring corresponding to the target office blood pressure of 130/80 mmHg was 129/79 mmHg and the daytime ambulatory blood pressure monitoring value corresponding to 140/90 mmHg at the office was 134/82 mmHg. As expected, discrepancies between ambulatory blood pressure monitoring and office blood pressure were due essentially to masked hypertension (about 10% of cases) and white coat hypertension (between 19% for systolic blood pressure and 26% for diastolic blood pressure). Interestingly, when office blood pressure was lower than 120 mmHg systolic and 70 mmHg diastolic, the sensitivity to rule out hypertension using ambulatory blood pressure monitoring was 90%. Similarly, when office blood pressure was more than 145 mmHg systolic and more than 90 mmHg diastolic the sensitivity to confirm hypertension using ambulatory blood pressure monitoring was 90%. Within these two sets of limits, 38% of patients would be misclassified if only office blood pressure values would be considered for the diagnosis. Thus, using the cut-off values of less than 120/70 mmHg and more than 140/90 mmHg at the office, 56% of the population sample would need an ambulatory blood pressure monitoring to confirm the diagnosis of hypertension. According to these results, only diabetics with an office blood pressure between 120 and 140 mmHg systolic and/or a diastolic blood pressure between 70 and 90 mmHg would really benefit from an out-office assessment of blood pressure. This would limit the use of ambulatory blood pressure monitoring to only 50% of the diabetic patients. Studies implications and limitations The results of this provide interesting practical information on the use of ambulatory blood pressure monitoring in diabetic patients. However, they also have some limitations. The first one is the fact that the entire analysis is based on daytime ambulatory blood pressure only. Although the authors have measured 24-h blood pressure, they have not considered the nighttime blood pressure. This is unfortunate because there is increasing evidence that nighttime is a better predictor of cardiovascular risk than daytime blood pressure. Moreover, diabetic patients are often characterized by an absence of the physiological fall in blood pressure reflecting a nondipping pattern at night. Diabetes may even be the cause of a reverse dipping, that is an increase in blood pressure at night. Both the nondipping and the reverse dipping pattern of blood pressure have been associated with an increased risk of developing target organ damages such as left ventricular hypertrophy, microalbuminuria, renal dysfunction, and cerebral vascular lesions [5,12]. Thus, when assessing the cardiovascular risk profile linked to hypertension in diabetic patients, nighttime blood pressure should be included. Indeed, it is not uncommon in diabetes that daytime normotensive patients exhibit a nocturnal hypertension. This type of patients would be misdiagnosed using the algorithm proposed by the authors. Recently, the results of the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial have shown that in diabetic patients the reduction of cardiovascular morbidity and mortality obtained by lowering office blood pressure below 120 mmHg systolic is not greater than that seen reducing blood pressure below 130 mmHg [13]. On the contrary, a systolic blood pressure below 120 mmHg may result in an increased risk of developing cardiac complications, as suggested by the recent post hoc analysis of diabetic patients with coronary heart diseases having participated in the INternational VErapamil SR-Trandolapril (INVEST) Study [14]. If a low blood pressure increases the risk of cardiac complications in diabetics, one might have to reconsider the necessity to perform an ambulatory blood pressure monitoring in diabetic patients with a blood pressure <120/70 mmHg in contrast to the proposals of Leitao et al. Indeed, in treated diabetic patients with a low office blood pressure, ambulatory blood pressure monitoring could be of importance to diagnosis episodes of asymptomatic hypotension episodes which might increase their cardiac risk. Thus, in the analysis of daytime and nighttime blood pressure values, it would be of interest to assess whether the percentage of ambulatory blood pressure values below a certain level is indeed associated with an increased risk of some cardiovascular complications. In this respect, it is important to mention that the analysis presented by Leitao et al. does not provide any information on the presence in this particular patients population of cardiac organ damage. The study also does not provide any data such on the occurrence of cardiovascular events and deaths, as it was not a prospective cohort study. Both these two sets of information should be thus provided by future clinical trials.

Ambulatory Blood Pressure in Chronic Kidney Disease: Ready for Prime Time?

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

To assess the effectiveness of postpartum home blood pressure (BP) monitoring compared with clinic-based follow-up and the comparative effectiveness of alternative home BP-monitoring regimens. Search of Medline, Cochrane, EMBASE, CINAHL, and ClinicalTrials.gov from inception to December 1, 2022, searching for home BP monitoring in postpartum individuals. We included randomized controlled trials (RCTs), nonrandomized comparative studies, and single-arm studies that evaluated the effects of postpartum home BP monitoring (up to 1 year), with or without telemonitoring, on postpartum maternal and infant outcomes, health care utilization, and harm outcomes. After double screening, we extracted demographics and outcomes to SRDR+. Thirteen studies (three RCTs, two nonrandomized comparative studies, and eight single-arm studies) met eligibility criteria. All comparative studies enrolled participants with a diagnosis of hypertensive disorders of pregnancy. One RCT compared home BP monitoring with bidirectional text messaging with scheduled clinic-based BP visits, finding an increased likelihood that at least one BP measurement was ascertained during the first 10 days postpartum for participants in the home BP-monitoring arm (relative risk 2.11, 95% CI 1.68-2.65). One nonrandomized comparative study reported a similar effect (adjusted relative risk [aRR] 1.59, 95% CI 1.36-1.77). Home BP monitoring was not associated with the rate of BP treatment initiation (aRR 1.03, 95% CI 0.74-1.44) but was associated with reduced unplanned hypertension-related hospital admissions (aRR 0.12, 95% CI 0.01-0.96). Most patients (83.3-87.0%) were satisfied with management related to home BP monitoring. Home BP monitoring, compared with office-based follow-up, was associated with reduced racial disparities in BP ascertainment by approximately 50%. Home BP monitoring likely improves ascertainment of BP, which is necessary for early recognition of hypertension in postpartum individuals, and may compensate for racial disparities in office-based follow-up. There is insufficient evidence to conclude that home BP monitoring reduces severe maternal morbidity or mortality or reduces racial disparities in clinical outcomes. PROSPERO, CRD42022313075.

Comparison of the measurement of the blood pressure in consultation versus home monitoring for the evaluation of the blood pressure targets in the diabetics of type 2