Ambulatory Blood Pressure (BP) Monitoring Research Articles

Incidence and risk factors for non-cardiac syncope in a cohort of patients addressing an accredited Arterial Hypertension Center: the Innocent Study.

Hypotensive susceptibility in hypertensive patients could facilitate orthostatic hypotension, syncope and fall. The aim of this study was to identify incidence, clinical form, complications and risk factors for non-cardiac syncope in a cohort of hypertensive patients. This is an observational, case-controlled, retrospective study carried out on 168 patients, evaluated at the Hypertension Center of the University Hospital of Parma (Italy). Based on the presence of episodes of syncope during the six months prior to enrolment, we identified cases and controls and then we compared them to personal data, comorbidities, current drug regimens, presence of orthostatic hypotension, office and ambulatory blood pressure monitoring (ABPM) blood pressure (BP) values. In patients with previous syncopal episodes (29.8% of total), we more frequently found female gender, comorbidities associated with autonomic dysfunction, diuretics and non-CV drugs potentially associated with hypotension in their current drug regimen, orthostatic hypotension and lower office and ABPM BP values. To identify hypertensive patients at higher risk for syncope and falls, physicians should focus on comorbidities and current drug regimens, systematically perform an active standing test to identify orthostatic hypotension, employ ABPM to compare BP values with the pre-established target and highlight systolic BP drops and abnormalities suggesting concomitant autonomic dysfunction. The modulation of antihypertensive therapy is an effective tool to counteract the risk of non-cardiac syncope, with possible trauma or other negative influences.

The severity of chronic heart failure and the parameters of daily blood pressure profile in patients with coronary heart disease

Aim: Although the prevalence of coronary heart disease (CHD) and hypertension which are the most common causes of the development and progression of chronic heart failure (CHF) is high, 24-hour ambulatory blood pressure (BP) monitoring (ABPM) in patients with CHF is not mandatory to be performed. The growing number of evidence suggests that excessive decrease in BP which clearly reflects increased BP variability (BPV) affects the survival of patients with heart failure (HF). The objective of the study was to investigate the relationship between the parameters specific to CHF severity and features of daily BP profiles in patients with ischemic CHF and hypertension. Methods: Ninety patients with functional class II–IV of CHF and CHD (the main group) and 50 non-CHF patients with hypertension (the comparative group) were examined. The transthoracic echocardiography (TTE) [atrial end-systolic dimension (ESD), ventricular end-diastolic dimension (EDD), left ventricular mass index (LVMI), and left ventricular ejection fraction (LVEF)] and 24-hour ABPM (BPV parameters and proportions of hypotensive episodes) were performed. The relationships between the abovementioned parameters were evaluated using the univariate correlation analysis and stepwise multiple linear regression. Results: Higher functional class of CHF is found to be associated with a higher incidence of daytime systolic BP (SBP) decline and nighttime SBP and diastolic BP (DBP) variability while higher LVEF is related to the hypotensive episodes regardless of CHF. Conclusions: It appears that the larger trials involving CHF patients with reduced LVEF should be conducted to clarify the obtained results.

Interventions aimed to increase average 24-h systolic blood pressure reduce blood pressure drops in patients with reflex syncope and orthostatic intolerance.

Systolic blood pressure (SBP) drops recorded by 24-h ambulatory blood pressure (BP) monitoring (ABPM) identify patients with susceptibility to reflex syncope and orthostatic intolerance. We tested the hypothesis that treatments aimed to increase BP (reassurance, education, and lifestyle measures plus pharmacological strategies) can reduce SBP drops. This was a multicentre, observational proof-of-concept study performed in patients with reflex syncope and/or orthostatic intolerance and with SBP drops on a screening ABPM. Among 144 eligible patients, 111 underwent a second ABPM on average 2.5 months after start of treatment. Overall, mean 24-h SBP increased from 114.1 ± 12.1 to 121.4 ± 14.5 mmHg (P < 0.0001). The number of SBP drops <90 and <100 mmHg decreased by 61%, 46% during daytime, and by 48% and 37% during 24-h period, respectively (P < 0.0001 for all). The dose-response relationship between difference in 24-h average SBP increase and reduction in number of SBP drops reached a plateau around ∼15 mmHg increase of 24-h SBP. The reduction in SBP drop rate was consistent and significant in patients who underwent deprescription of hypotensive medications (n = 44) and in patients who received BP-rising drugs (n = 67). In patients with reflex syncope and/or orthostatic intolerance, an increase in average 24-h SBP, regardless of the implemented strategy, significantly reduced the number of SBP drops and symptom burden. A 13 mmHg increase in 24-h SBP appears to represent the optimal goal for aborting the maximal number of SBP drops, representing a possible target for future interventions. ClincalTrials.gov identifier: NCT05729724.

A comparative trial of blood pressure monitoring in a self-care kiosk, in office, and with ambulatory blood pressure monitoring

BackgroundAutomated measurement of blood pressure (BP) in designated BP kiosks have in recent years been introduced in primary care. If kiosk blood pressure (BP) monitoring provides results equivalent to in-office BP or daytime ambulatory BP monitoring (ABPM), follow-up of adult patients could be managed primarily by self-checks. We therefore designed a comparative trial and evaluated the diagnostic performance of kiosk- and office-based BP (nurse- versus physician-measured) compared with daytime ABPM.MethodsA trial of automated BP monitoring in three settings: a designated BP kiosk, by nurses and physicians in clinic, and by ABPM. The primary outcome was systolic and diastolic BP, with respective diagnostic thresholds of ≥135 mmHg and/or ≥ 85 mmHg for daytime ABPM and kiosk BP and ≥ 140 mmHg and/or ≥ 90 mmHg for office BP (nurse- and physician-measured).ResultsCompared with daytime ABPM, mean systolic kiosk BP was higher by 6.2 mmHg (95% confidence interval [CI] 3.8–8.6) and diastolic by 7.9 mmHg (95% CI 6.2–9.6; p < 0.001). Mean systolic BP taken by nurses was similar to daytime ABPM values (+ 2.0 mmHg; 95% CI − 0.2–4.2; p = 0.071), but nurse-measured diastolic values were higher, by 7.2 mmHg (95% CI 5.9–9.6; p < 0.001). Mean systolic and diastolic physician-measured BPs were higher compared with daytime ABPM (systolic, by 7.6 mmHg [95% CI 4.5–10.2] and diastolic by 5.8 mmHg [95% CI 4.1–7.6]; p < 0.001). Receiver operating characteristic curves of BP monitoring across pairs of systolic/diastolic cut-off levels among the three settings, with daytime ABPM as reference, demonstrated overall similar diagnostic performance between kiosk and nurse-measured values and over the curve performance for physician-measured BP. Accuracy with nurse-measured BP was 69.2% (95% CI 60.0–77.4%), compared with 65.8% (95% CI 56.5–74.3%) for kiosk BP.ConclusionsIn this study kiosk BP monitoring was not comparable to daytime ABPM but could be an alternative to in-office BP monitoring by trained nurses. The diagnostic performance of kiosk and nurse-measured BP monitoring was similar and better than that of physician-measured BP.Trial registrationClinicalTrials.gov (NCT04488289) 27/07/2020.

The correlation between ambulatory blood pressure parameters and cardiovascular risk factors in older adults with high-risk hypertension

Objective: To explore the correlation of 24-hour ambulatory blood pressure (BP) monitoring (ABPM) parameters and cardiovascular risk factors in older adults with high-risk hypertension. Material and method: A cross-sectional study was conducted on 96 older adults (≥ 60 years old) with treated high-risk hypertension. Socio-demographic and cardiovascular risk information were gathered. The patients were performed 24-hour ABPM. Results: The mean age was 70.88 ± 7.86 years, and 64.6% were women. The prevalence of cardiovascular risk factors was as follows: dyslipidemia: 80.2%, family history of hypertension: 54.2%, diabetes mellitus: 51%, smoking: 24%, prior stroke: 11.5%. Significant differences in 24-hour, awake, and sleep systolic BP were observed between men and women. There were significant correlations between 24-hour mean systolic BP with age (r = 0.229, p = 0.025), dyslipidemia (r = 0.223, p = 0.029), family history of hypertension (r = 0.214, p = 0.036), BMI (r = 0.212, p = 0.039), waist circumference (r = 0.226, p = 0.027) and creatinine level (r = 0.207, p = 0.043). There were significant correlations between 24-hour mean diastolic BP with BMI (r = 0.289, p = 0.004) and prior stroke (r = -0.224, p = 0.029). There were significant correlations between 24-hour mean BP with BMI (r = 0.268, p = 0.009), waist circumference (r = 0.220, p = 0.032) and prior stroke (r = -0.215, p = 0.036). Conclusion: There were significant correlations between ABPM parameters and cardiovascular risk factors in older adults with high-risk hypertension. Key words: 24-hour ambulatory blood pressure, cardiovascular risk factors, high-risk hypertension, older adults, correlation.

Race differences in ambulatory blood pressure monitoring parameters.

Mean systolic and diastolic blood pressure (SBP and DBP) on ambulatory blood pressure (BP) monitoring (ABPM) are higher among Black compared with White adults. With 48 to 72 BP measurements obtained over 24 h, ABPM can generate parameters other than mean BP that are associated with increased risk for cardiovascular events. There are few data on race differences in ABPM parameters other than mean BP. To estimate differences between White and Black participants in ABPM parameters, we used pooled data from five US-based studies in which participants completed ABPM (n = 2580). We calculated measures of SBP and DBP level, including mean, load, peak, and measures of SBP and DBP variability, including average real variability (ARV) and peak increase. There were 1513 (58.6%) Black and 1067 (41.4%) White participants with mean ages of 56.1 and 49.0 years, respectively. After multivariable adjustment, asleep SBP and DBP load were 5.7% (95% CI: 3.5-7.9%) and 2.7% (95% CI: 1.1-4.3%) higher, respectively, among Black compared with White participants. Black compared with White participants also had higher awake DBP ARV (0.3 [95%CI: 0.0-0.6] mmHg) and peak increase in DBP (0.4 [95% CI: 0.0-0.8] mmHg). There was no evidence of Black:White differences in awake measures of SBP level, asleep peak SBP or DBP, awake and asleep measures of SBP variability or asleep measures of DBP variability after multivariable adjustment. Asleep SBP load, awake DBP ARV and peak increase in awake DBP were higher in Black compared to White participants, independent of mean BP on ABPM.

Influence of Recent Standing, Moving, or Sitting on Daytime Ambulatory Blood Pressure.

Background There are no recommendations for being seated versus nonseated during ambulatory blood pressure (BP) monitoring (ABPM). The authors examined how recent standing or moving versus sitting affect average daytime BP on ABPM. Methods and Results This analysis used baseline assessments from a clinical trial in desk workers with office systolic BP (SBP) 120 to 159 mm Hg or diastolic BP (DBP) 80 to 99 mm Hg. ABPM was measured every 30 minutes with a SunTech Medical Oscar 2 monitor. Concurrent posture (standing or seated) and moving (steps) were measured via a thigh-worn accelerometer. Linear regression determined within-person BP variability explained (R2) by standing and steps before ABPM readings. Mean daytime BP and the prevalence of mean daytime BP >135/85 mm Hg from readings after sitting (seated) or after recent standing or moving (nonseated) were compared with all readings. Participants (n=266, 59% women; age, 45.2±11.6 years) provided 32.5±3.9 daytime BP readings. Time standing and steps before readings explained variability up to 17% for daytime SBP and 14% for daytime DBP. Using the 5-minute prior interval, seated SBP/DBP was lower (130.8/79.7 mm Hg, P<0.001) and nonseated SBP/DBP was higher (137.8/84.3 mm Hg, P<0.001) than mean daytime SBP/DBP from all readings (133.9/81.6 mm Hg).The prevalence of mean daytime SBP/DBP ≥135/85 mm Hg also differed: 38.7% from seated readings, 70.3% from nonseated readings, and 52.6% from all readings (P<0.05). Conclusions Daytime BP was systematically higher after standing and moving compared with being seated. Individual variation in activity patterns could influence the diagnosis of high BP using daytime BP readings on ABPM.

HUNGARIAN AMBULATORY BLOOD PRESSURE MONITORING REGISTRY REVEALED THAT HYPERTENSION IS HIGHLY PREVALENT BOTH IN ALREADY DIAGNOSED AND TREATED PATIENTS AND IN SUSPECTED HYPERTENSIVES

Objective: In 2021 the Hungarian Society of Hypertension initiated a program to promote the nationwide use of ambulatory blood pressure (BP) monitoring (ABPM) (Hungarian ABPM Registry) aiming to increase the awareness of high BP and to monitor the efficacy of therapies. The goal was to collect and analyze the ABPM values of treated hypertensive (HT) and newly diagnosed patients (nHT) and assess the influence of other risk factors, comorbidities and patient characteristics. Design and method: Adults (18-100 years old) can be included into this ongoing, multicenter, open-label, observational study. Data collection to an electronic case report form is performed by GPs, internists, and cardiologists. Meditech ABPM-06 monitors are used. Data of the current analysis were collected between 21.02.2021-5.10.2022. 15 835 ABPMs were performed; due to missing data or protocol deviation 1018 patients were excluded from the analysis. Results: 10212 patients were HTs, 4571 were nHTs (69% and 31%, respectively). 76% of nHT patients were untreated during ABPM. Mean 24-hour systolic and diastolic BP was 134.03±14.6 mmHg and 79.3±10.1 mmHg, respectively. There was no difference in the 24-hour mean systolic BP between nHT and HT patients (134.08±14.9 mmHg vs. 133.91±14.6 mmHg, respectively, p = NS). Two-third of the patients (all: 68.2%, HT: 68.5%, nHT: 67.6%) were hypertensive according to ABPM measurements. Obesity (BMI&gt;30 kg/m2) doubled the risk of hypertension in both groups (OR = 2.18 [2.03;2.34] for 24-hour average), but it had a higher impact in nHTs (OR = 2.57[2.22;2.98] for 24-hour average in nHT and OR = 2.12[1.94;2.30] for 24-hour average in HT patients). Snoring increased the risk of hypertension in both group of patients (OR = 1.45[1.34;1.56] for 24-hour average) irrespectively of gender, and – interestingly – it had a greater impact on the daily values of BP (day: OR = 1.51[1.40;1.62] and night: OR = 1.32[1.22;1.42]). Conclusions: The new ABPM Hungary Registry revealed hypertension in the majority of screened individuals, regardless of gender or treatment. In addition, in both gender, obesity, snoring, increased the risk of hypertension. These data underline the importance of ABPM in the screening for and treatment of hypertension leading to the earlier and more effective treatment.

PATIENT CHARACTERISTICS OF A REAL WORLD REGISTRY OF AMBULATORY BLOOD PRESSURE MONITORING: DATA FROM THE NEW HUNGARIAN ABPM REGISTRY

Objective: Current European guidelines recommend ambulatory blood pressure (BP) monitoring (ABPM) for the diagnosis and follow-up of patients with known or suspected hypertension. Thus in 2021 the Hungarian Society of Hypertension initiated a nationwide registry in order to evaluate ABPM indications and patient characteristics. Design and method: This is an ongoing, multicenter, open-label, observational study. Data collection to an electronic case report form is performed by GPs, internists and cardiologists. For ABPM measurements Meditech-ABPM-06 monitors are used. Data of the current analysis were collected between 21.02.2021-5.10.2022. 15 835 ABPMs were performed; due to missing data or protocol deviation 1018 patients were excluded from the analysis. Results: 10 212 patients were known and treated hypertensives (HT), and 4 571 were newly diagnosed or suspected hypertensives (nHT) (69% and 31%, respectively; females: 51.1%, males 48.9%). 76% of the nHTs were untreated. They were 12 years younger than HT patients (46.7 ± 13.9 and 59.1 ± 13.9 years old, respectively p&lt;0.001). Besides high BP, other atherosclerotic risk factors and comorbidities were less frequent in nHT patients than in HT patients: dyslipidemia was known only in 11.8% vs. 28.7%, obesity (BMI &gt; 30 kg/m2) in 32.2% vs. 40.3%, diabetes 2.7% vs. 13.1%, coronary heart disease in 0.8% vs. 9.6% of patients, respectively. In the HT group compared to the nHT group there were more cerebrovascular (3.3% vs 0.8%, p&lt;0.001) and peripheral arterial diseases (1.8% vs 0.4%, p&lt;0.001). In both groups the main indication of ABPM was high (62%) or labile (39.5%) home BP values. More ABPMs were performed in the nHT group because of the suspicion of white-coat- (19.2% vs. 9.0%, p&lt;0.001), or masked hypertension (3.9% vs. 0.9%, p&lt;0.001). Hypertension was diagnosed by the largest percentage in patients with suspected resistant hypertension (83%) and by the lowest percentage with suspected nocturnal hypertension (57%). Conclusions: The major indications for ABPM are the high or labile home BP values. Among nHTs suspected white coat hypertension is the third most important indication for ABPM, while in HT patients the follow up of therapies. Additional risk factors and comorbidities are less known in nHTs.

AMBULATORY BLOOD PRESSURE MONITORING BEFORE AND AFTER TREATMENT IN SECONDARY FORMS OF HYPERTENSION

Objective: Studies using ambulatory blood pressure (BP) monitoring (ABPM) have reported that in some secondary forms of hypertension the normal nocturnal BP decrease is blunted. Design and method: The aim of our study was to compare the nocturnal BP decrease in patients with secondary hypertension before and after treatment. ABPM was performed using the validated Meditech ABPM-06. ABPM readings were obtained at 30-minute intervals for 24-hour in patients with secondary hypertension before and after treatment. The diagnosis of secondary hypertension was based on the history and laboratory data: plasma and urinary electrolytes, renal function, calcium-phosphorus system, the renin-angiotensin-aldosterone system, urinary free cortisol, suppressibility of cortisol after 1 mg dexamethasone, plasma adrenocorticotropic hormone, plasma D4 androstenedione, plasma dehydroepiandrosterone sulphate, plasma 17-alpha hydroxyprogesterone, plasma testosterone, and urinary metanephrine. BP decrease were studied in the following groups: 42 patients with primary aldosteronism (19 men and 23 women; mean age, 44±12 years), 25 patients with adrenal pheochromocytoma (11 men and 14 women; mean age, 42±13 years), and 55 patients with Cushing's syndrome (18 men and 37 women, mean age, 43±13 years). Results: Average systolic/diastolic BP decrease was: before 2/1 mmHg and after 8/6 mmHg treatment in patients with primary aldosteronism. Average systolic/diastolic BP decrease was: before 4/5 mmHg and after 9/12 mmHg treatment in patients with adrenal pheochromocytoma. Average systolic/diastolic BP decrease was: before 3/2 mmHg and after 11/9 mmHg treatment in patients with Cushing's syndrome. All differences in systolic/diastolic BP decrease were statistically significant, with a P value &lt;.001 Conclusions: The results of our study confirm that secondary causes of hypertension lead to a reduced decrease in blood pressure during sleep. After proper treatment reduction in nighttime BP normalizes. A detailed analysis of ABPM can lead us to find the accurate etiology of hypertension.

CLINICAL EFFECTS OF SINGLE PILL COMBINATION THERAPY OF ANTIHYPERTENSIVES AND STATIN ON BLOOD PRESSURE, LIPID, AND CARDIOVASCULAR RISK PROFILES IN PATIENTS WITH NEWLY DIAGNOSED HYPE

Objective: Hypertension and dyslipidemia are the major risk factors for athersclerotic cardiovascular disease (ASCVD). The single pill combination (SPC) covering these risk factors are commonly used but has little data. The clinical effect of these SPCs on blood pressure and lipid profile with ASCVD risk change were evaluated in middle aged borderline risk group. Design and method: Seventy-two patients (age: 53.6±10 years) who were simultaneously diagnosed with hypertension and dyslipidemia were randomized to the two SPC groups: amlodipine 5 with atorvastatin 20 (AA) versus (vs.) olmesartan20 with rosuvastatin 10mg (OR). Before and after medication for six months under the active life style change, 24-hour ambulatory blood pressure (BP) monitoring (ABPM), lipid profile, carotid ultrasonography, ankle-brachial index (ABI), and ASCVD risk parameters including glucose profiles were also compared. Results: Baseline 24-hr mean systolic BP were higher in OR group (AA vs. OR: systolic BP 142.8±8.9 vs. 148.3±8.8mmHg, p = 0.039). The level of LDL cholesterol were slightly higher without significance in OR group (LDL 121.3±31.2 vs. 136.4±26.6mg/dL, p = 0.091). Follow-up mean BP were similar on 24-hr ABPM (systolic BP 127.3±9.4 vs. 125.1±7.3mmHg, p = 0.416; diastolic BP 85.6±6.6 vs. 81.4±7.8mmHg, p = 0.083). The changes in reduction of mean systolic BP markedly greater in OR group (systolic BP -15.1±11.5 vs -22.8±11.7, p = 0.048). Reduction of LDL cholesterol were similar (-53.1±24.7 vs. -62.5±29.1 mg/dL, p = 0.331). The level of fasting glucose was increased in only OR group and those of hemoglobin A1c were increased at both group and its changes were greater in OR group (0.12±0.30 vs. 0.23±0.28%, p = 0.048). The carotid intima-media thicknesses were slightly reduced in both group while ABI were not changed. ASCVD risk score were decreased after treatment (5.3 to 2.9 vs. 6.9 to 3.8%) with its similar rate between both group (45.3 vs 45.6%). Conclusions: In treating the middle aged patients with newly diagnosed hypertension and dyslipidemia using SPCs of AA and OR, OR is beneficial in blood pressure control while AA is advantageous to glucose control. After 6-months simultaneous treatment of hypertension and dyslipidemia, their grades of ASCVD risks were shifted from borderline to lower group.

Morning blood pressure surge as a predictor of cardiovascular events in patients with hypertension.

The prognostic value of ambulatory blood pressure (BP) monitoring (ABPM) is poorly understood in Latin American populations. A prospective observational study was conducted on 1339 patients with hypertension who underwent 24-h BP monitoring between 2015 and 2019. The incidence of serious adverse cardiovascular events (MACE) was analysed using a Cox proportional hazards model adjusted for potential confounders. Three previously reported morning surge definitions were evaluated for SBP and DBP using different ABPM components: sleep-through morning surge, pre-awakening, and morning night-time difference. The mean age was 62 years, 52% were female, 32.8% had dyslipidaemia, 27.2% were smokers, and 7.8% had diabetes. During a median follow-up period of 32 months, 197 MACE occurred. In men, the adjusted hazard ratio (HR) was 1.84 [95% confidence interval (CI), 1.35-2.49; P < 0.001). The HR increased to 2.03 (95% CI, 1.89-2.17; P < 0.001) with a cut-off value of 35 mmHg for a 10 mmHg increase in sleep-through morning surge. The increased adjusted HR associated with the morning rise persisted for each secondary endpoint, including 21 cardiovascular deaths [HR: 2.70 (95% CI, 2.03-3.60; P < 0.001)], 78 myocardial infarctions [HR: 1.92 (95% CI, 1.72-2.15; P < 0.001)], 24 hospitalisations for heart failure [HR: 1.77 (95% CI, 1.48-2.12; P < 0.001)], 22 strokes [HR: 2.32 (95% CI, 1.85-2.91; P < 0.001)], and 52 atrial fibrillations [HR: 1.94 (95% CI, 1.71-2.20; P < 0.001)]. The morning BP rise was the most important circadian prognostic factor for MACE in patients with hypertension, which deserves more attention.

Impact of reboxetine plus oxybutynin treatment for obstructive sleep apnea on cardiovascular autonomic modulation

The combination of noradrenergic (reboxetine) plus antimuscarinic (oxybutynin) drugs (reb-oxy) reduced obstructive sleep apnea (OSA) severity but no data are available on its effects on cardiac autonomic modulation. We sought to evaluate the impact of 1-week reb-oxy treatment on cardiovascular autonomic control in OSA patients. OSA patients were randomized to a double-blind, crossover trial comparing 4 mg reboxetine plus 5 mg oxybutynin to a placebo for OSA treatment. Heart rate (HR) variability (HRV), ambulatory blood pressure (BP) monitoring (ABPM) over 24 h baseline and after treatment were performed. Baroreflex sensitivity was tested over beat-to-beat BP recordings. 16 subjects with (median [interquartile range]) age 57 [51–61] years and body mass index 30 [26–36]kg/m2 completed the study. The median nocturnal HR was 65 [60–69] bpm at baseline and increased to 69 [64–77] bpm on reb-oxy vs 66 [59–70] bpm on placebo (p = 0.02). The mean 24 h HR from ABPM was not different among treatment groups. Reb-oxy administration was not associated with any modification in HRV or BP. Reb-oxy increased the baroreflex sensitivity and did not induce orthostatic hypotension. In conclusion, administration of reb-oxy did not induce clinically relevant sympathetic overactivity over 1-week and, together with a reduction in OSA severity, it improved the baroreflex function.

Position of 24-hour ambulatory blood pressure monitoring in modern practice

Currently, 24-hour ambulatory blood pressure (BP) monitoring (ABPM) is the gold standard for diagnosing hypertension (HTN) and evaluating the effectiveness of antihypertensive therapy. The method provides information about some BP parameters that cannot be obtained in any other way. ABPM is reasonable in any patient with a documented increase in BP, especially if specific BP phenotypes are suspected: white coat HTN and masked HTN. Antihypertensive therapy under the ABPM, on average, is more economical and is not associated with overprescribing of drugs and their combinations. Based on the ABPM data, calculating a number of additional indicators of the 24-hour BP profile is possible, but their scope is still limited to the research field. In the conclusion on ABPM data, the results of office BP measurement and antihypertensive therapy should be indicated.

Abstract 13192: The Influence of Posture and Steps on Daytime Ambulatory Blood Pressure

Introduction: Ambulatory blood pressure (BP) monitoring (ABPM) provides data beyond clinic BP. Yet, free-living activity prior to measurements may add variability and obscure clinical interpretation. The influence of posture and ambulation on ABPM is unclear. Hypothesis: Posture and ambulation will partially explain variability in daytime ABPM. Methods: This study used baseline data from RESET BP (NCT03307343), a randomized clinical trial testing a sedentary behavior reduction intervention among inactive desk workers with elevated, unmedicated BP. ABPM was measured 2 x per self-reported waking hour over 24 hours with a SunTech Medical ® Oscar 2 TM ambulatory BP monitor. Upright posture and step count were concurrently captured with an activPAL TM thigh-worn accelerometer. Upright time and steps were summed for the 1-, 5-, 10-, and 15-minute intervals prior to each ABPM measurement. Percentage of BP variability explained (R 2 ) by upright time, steps, and both was calculated within-subject using linear regression. Additional models considered quadratic terms for upright time and steps. Results: Participants (n=256) were 59% female, with mean±SD age of 45.2±11.6 years, resting systolic BP (SBP) of 130±10 and diastolic BP (DBP) of 84±7, and provided 32.5±3.9 daytime ABPM measurements. Upright time and steps were directly associated with BP. Upright time and steps explained the most variability (highest R 2 ) using the 1-minute interval prior to ABPM measurement; R 2 gradually declined with increasing interval length. From 1-minute prior, upright time explained 12% of the variability in SBP and 10% of DBP, on average. Adding an upright time quadratic term increased R 2 (SBP: 16%; DBP: 13%). Steps in the minute prior explained 12% and 7% of the variability in SBP and DBP, respectively, and increased to 16% and 11% with the addition of a quadratic term. A final model including upright time, steps, and quadratic terms explained 25% and 20% of the variability in SBP and DBP, respectively. Conclusions: Posture and steps, especially in the minute prior, explained a substantial amount of individual variability in ABPM. These findings advance our understanding of BP variability and may have implications for the quantification and interpretation of daytime ABPM data.

Abstract P223: Hypertension Telemonitoring And Protocolized Case Management For Community-Dwelling Older Adults: A Randomized Controlled Trial

Background: Home blood pressure (BP) telemonitoring combined with case management leads can reduce BP in adults with hypertension. However, the benefits of telemonitoring and case management for hypertension are not well established in older (age &gt;= 65 years) adults. Interventions that can safely improve BP control in this distinct group will be critically important, particularly given recent trials showing cardiovascular benefits of intensive BP lowering in this group, and their increased vulnerability to over-treatment-related side effects. Methods: Twelve-month, open-label, randomized controlled trial of community-dwelling older adults comparing home BP telemonitoring (HBPM) with pharmacist-led case management versus enhanced usual care with HBPM alone. The primary outcome was the proportion achieving age-specific systolic BP targets on 24-hour ambulatory BP monitoring (ABPM). Changes in HBPM were also examined. Logistic and linear regression were used for analyses, with adjustment for baseline BP. Results: Subjects randomized to intervention (n = 61) and control (n = 59) groups were mostly female (77%), with mean age of 79.5 years. The adjusted odds ratio (aOR) for ABPM BP target achievement was 1.48 (95% CI 0.87-2.52, p = 0.15). At 12 months, the mean difference in BP changes between intervention and control groups was -1.6/-1.1 for ABPM (p-value 0.26 for systolic and 0.10 for diastolic BP), and -4.9/-3.1 for HBPM (p-value 0.04 for systolic BP and 0.01 for diastolic BP), favoring the intervention. Intervention group subjects had a higher rate of systolic BP &lt; 110 (21% vs 5%, p = 0.009), but no differences in orthostatic symptoms, syncope, non-mechanical falls, or ED visits. Adherence to HBPM declined by 12 months, with 65% of trial-completers providing all 4 of the study-driven 3-monthly HBPM series. Conclusions: Home BP telemonitoring and pharmacist case management did not improve achievement of target range ambulatory BP, but did reduce home BP. It was not associated with major adverse consequences. Further trials will be necessary to refine HBPM interventions, improve adherence, and determine effectiveness in older individuals more conclusively.

Smartphone Application-Assisted Home Blood Pressure Monitoring Compared With Office and Ambulatory Blood Pressure Monitoring in Patients With Hypertension: the AMUSE-BP Study.

Background:The development of automated, smartphone application (app)-assisted home blood pressure monitoring (HBPM) allows for standardized measurement of blood pressure (BP) at home. The aim of this study was to evaluate the (diagnostic) agreement between app-assisted HBPM, automated office BP (OBP), and the reference standard 24-hour ambulatory BP monitoring (ABPM).Methods:In this open randomized 5-way cross-over study, patients diagnosed with hypertension were randomized to one of 10 clusters, each containing 5 BP measurement methods (ABPM, HBPM, attended OBP, unattended OBP, and unattended 30-minute BP) in different order.Results:In total, 113 patients were included. The average 24-hour ABPM was 126±11/73±8 mm Hg compared with 141±14/82±10 mm Hg with app-assisted HBPM, 134±13/80±9 mm Hg with unattended 30-minute BP, 137±16/81±11 mm Hg with attended OBP, and 135±15/81±10 mm Hg with unattended OBP monitoring. Diagnostic agreement between app-assisted HBPM and 24-hour ABPM for diagnosing sustained (OBP >140/90 mm Hg and ABPM ≥130/80 mm Hg or HBPM ≥135/85 mm Hg), white-coat (OBP ≥140/90 mm Hg and ABPM <130/80 mm Hg or HBPM <135/85 mm Hg), and masked hypertension (OBP <140/90 mm Hg and ABPM ≥130/80 mm Hg or HBPM ≥135/85 mm Hg) was fair-to-moderate (κ statistics ranging from 0.34 to 0.40). App-assisted HBPM had high sensitivities (78%–91%) and negative predictive values (90%–97%) for diagnosing sustained and masked hypertension.Conclusions:This study showed a considerable (diagnostic) disagreement between app-assisted HBPM and ABPM. App-assisted HBPM had high sensitivity in the diagnosis of sustained and masked hypertension and may therefore be used as complementary to, but not a replacement of, ABPM.

Home Blood Pressure monitoring: An economical, reliable, and convenient Tool over ambulatory Blood Pressure monitoring in Patients on Dialysis.

Hypertension and cardiovascular disease (CVD) is the leading cause of morbidity and mortality in patients on dialysis. Blood pressure (BP) control is of paramount importance in reducing morbidity and mortality in this high-risk population, although there is no consensus on target BP. Ambulatory BP recording is considered gold standard in estimating the BP among patients on dialysis. But, ambulatory BP recording is cumbersome, not economical, and not easily available to Indian patients. Therefore, an easier and more convenient method has to be implemented to monitor the BP. Some studies demonstrated that home BP recordings may be promising in making a more accurate diagnosis of hypertension in hemodialysis patients. However, there is paucity of research that compares home-based BP monitoring with ambulatory BP recordings in patients on hemodialysis. The present study was thus planned to examine the hypothesis that out-of-dialysis unit BP measurement in the form of home-based measurement of BP is as efficacious as ambulatory BP monitoring (ABPM) in evaluating hypertension among patients on hemodialysis. To assess the accuracy of home-based BP monitoring in comparison to ABPM among chronic kidney disease (CKD) patients on hemodialysis. To assess the ability of home-based BP monitoring to detect hypertension among CKD patients on hemodialysis. This was a prospective observational study carried out in the Department of Medicine in a tertiary care hospital. The total duration of the study was 24 months. Fifty-two CKD patients on hemodialysis fulfilling the eligibility criteria were taken up for the study after informed consent. Blood pressure was measured using a standardized BP measuring equipment at home, thrice a day for 3 days in the interdialysis period. Also, all these patients were subjected to 24 hours of ABPM in the interdialysis period. Home-based BP monitoring records are then compared with the one-time ABPM records. All statistical calculations were done using computer programs Microsoft Excel 2007 (Microsoft Corporation, NY, USA) and SPSS (Statistical Product and Service Solutions; SPSS Inc., Chicago, Illinois, USA) version 21. In our study, the mean awake, asleep, and average ABPM readings of systolic blood pressure (SBP) and diastolic blood pressure (DBP) were 141.69/81.33, 139.39/80.04, and 141.23/80.67 mm Hg, respectively, while the mean SBP and DBP recorded on home-based measurements were 143.6 and 82.69 mm Hg, respectively. All the subjects showing mean SBP ≥140 mm Hg as per ABPM had home-based readings of above 140 mm Hg while 23 out of 27 patients (85.2%) with mean SBP &lt;140 mm Hg as per ABPM had similar observation by home-based monitoring (kappa 0.847; p&lt;0.01). All the subjects showing mean DBP ≥90 mm Hg as per ABPM had home-based readings of above 90 mm Hg while 42 out of 44 patients (95.5%) with mean DBP &lt;90 mm Hg as per ABPM had similar observation by home-based monitoring (kappa 0.866; p&lt;0.01). Our study shows that there is no difference between BP readings as observed by ABPM and home-based BP monitoring. Also, home-based BP monitoring can detect hypertension as effectively as ABPM among patients on hemodialysis, thereby making home-based BP monitoring a safe and reliable method of BP measurement in clinical practice.

Telemonitoring and protocolized case management for hypertensive community dwelling older adults (TECHNOMED): a randomized controlled trial.

Home blood pressure (BP) telemonitoring combined with case management leads to BP reductions in individuals with hypertension. However, its benefits are less clear in older (age ≥ 65 years) adults. Twelve-month, open-label, randomized trial of community-dwelling older adults comparing the combination of home BP telemonitoring (HBPM) and pharmacist-led case management, vs. enhanced usual care with HBPM alone. The primary outcome was the proportion achieving systolic BP targets on 24-h ambulatory BP monitoring (ABPM). Changes in HBPM were also examined. Logistic and linear regressions were used for analyses, adjusted for baseline BP. Enrollment was stopped early due to coronavirus disease 2019. Participants randomized to intervention (n = 61) and control (n = 59) groups were mostly female (77%), with mean age 79.5 years. The adjusted odds ratio for ABPM BP target achievement was 1.48 (95% confidence interval 0.87-2.52, P = 0.15). At 12 months, the mean difference in BP changes between intervention and control groups was -1.6/-1.1 for ABPM (P-value 0.26 for systolic BP and 0.10 for diastolic BP), and -4.9/-3.1 for HBPM (P-value 0.04 for systolic BP and 0.01 for diastolic BP), favoring the intervention. Intervention group participants had hypotension (systolic BP < 110) more frequently (21% vs. 5%, P = 0.009), but no differences in orthostatic symptoms, syncope, non-mechanical falls, or emergency department visits. Home BP telemonitoring and pharmacist case management did not improve achievement of target range ambulatory BP, but did reduce home BP. It did not result in major adverse consequences.

Evaluating novel approaches for estimating awake and sleep blood pressure: design of the Better BP Study – a randomised, crossover trial

IntroductionFor many people, blood pressure (BP) levels differ when measured in a medical office versus outside of the office setting. Out-of-office BP has a stronger association with cardiovascular disease (CVD)...