Background Blood Pressure Research Articles

Association of baseline blood pressure and outcomes in etiology subtypes of large vessel occlusion stroke: Data from ANGEL-ACT registry

BackgroundBlood pressure (BP) management at the initial stage of stroke caused by large-vessel occlusion (LVO) remains challenging. We assessed the association between baseline BP and clinical and safety outcomes of endovascular treatment (EVT) in different stroke etiologies. MethodsPatients with acute ischemic stroke and anterior circulation LVO were screened from a prospective, multicenter registry of EVT from November 2017 to March 2019. The primary outcome was poor 90-day outcome (modified Rankin Scale score 3–6). The safety outcome was 24 h post-procedure parenchymal hematoma (PH). The Trial of Org 101072 in Acute Stroke Treatment criteria were used for etiologic stroke classification. Restricted cubic spline and binary logistic regression analysis were performed to examine the association between study outcomes and natural log-transformed BP. ResultsIn subgroup analyses, a U-shaped correlation existed between baseline mean arterial pressure (MAP) and poor outcome in large-artery atherosclerosis stroke only. Higher MAP was an independent risk factor compared with a central reference value (≥ 133 mm Hg vs 96–115 mm Hg; adjusted OR [aOR], 2.50; 95 % CI, 1.09 to 5.71, P = 0.030). Whereas elevated MAP was associated with PH (aOR, 1.58; 95 % CI 1.04 to 2.39, P = 0.030 for a ln10-unit increase in natural log-transformed MAP) in the range <110 mm Hg exclusively for cardioembolic stroke. ConclusionWhether it is cause or epiphenomenon, baseline BP was associated with 90-day outcome in large-artery atherosclerosis stroke, whereas in cardioembolic stroke baseline BP was correlated with post-procedure PH within a certain range. Identifying these features based on etiological subtypes may offer a reference for BP management in acute LVO stroke.

DeliVERy of optimal blood pressure coNtrol in afrICA (VERONICA)-Nigeria study: Rationale and design of a randomized clinical trial

BackgroundBlood pressure (BP) control among treated patients in Africa is very suboptimal, with low levels of combination therapy use and therapeutic inertia being among the major barriers to effective control of hypertension. The VERONICA-Nigeria study aims to evaluate, among Black African adults with hypertension, the effectiveness and safety of a triple pill-based treatment protocol compared to Nigeria hypertension treatment protocol for the treatment of hypertension. MethodsThis study involves a randomised, parallel-group and open-label trial. Adults with uncontrolled hypertension (n=300), untreated or receiving monotherapy, with no contraindication to study treatments will be randomly assigned 1:1 to treatment with a triple pill based-treatment protocol or Nigeria hypertension treatment protocol. Follow-up is for 6 months, with interim follow up visits at month 1, 2, and 3. In a non-comparative extension treatment period, participants completing the 6 months randomised period and on ≤3 BP-lowering drugs will receive treatment with the triple pill-based treatment protocol for 12 months. The primary outcome is change in home mean SBP from baseline to month 6, and key secondary efficacy outcome is percentage of participants with clinic BP <140/90 mmHg at month 6. The primary safety outcome is discontinuation of trial treatment due to adverse events from randomization to month 6. Economic evaluation will be conducted to assess the cost-effectiveness of the triple pill-based treatment protocol, and process evaluation will be conducted to understand the context in which the trial was conducted, implementation of the trial and interventions and mechanisms of effect, and potential barriers and facilitators to implementing the intervention in clinical practice. ConclusionThe VERONICA-Nigeria trial will provide evidence of effectiveness and safety of the triple-based treatment protocol for the pharmacological management of hypertension, in Black African adults. Trial RegistrationPACTR202107579572114

Blood Pressure: The History and Development of Monitoring Modalities

Background Blood pressure (BP) is one of the most frequently measured and monitored physiologic vital signs by all stroke clinicians, yet data suggest that only 1 out of 5 clinicians applies evidence-based methods for BP monitoring. Methods An exhaustive review of the literature was conducted and assembled to provide a historical clinical account of BP monitoring modalities and related evidence-based clinical methods. Results Evidence-based clinical methods are described for use of manual sphygmomanometry, noninvasive oscillometric automatic BP (NIBP) monitors, and arterial lines. Implications for practice are discussed in relation to provision of acute and critical care of ischemic and hemorrhagic stroke patients. Conclusion Use of evidence-based BP monitoring methods ensures accurate management of highly vulnerable stroke patients. Knowledge of the history of BP monitoring, along with the benefits and limitations of different measurement methods enables accuracy in BP treatment, benefitting stroke patient outcomes.

DAYTIME SUPINE BLOOD PRESSURE NORMALIZED BY 24-HOUR VALUES INDEPENDENTLY PREDICTS FUNCTIONAL OUTCOME AFTER ISCHEMIC STROKE

Objective: Blood pressure (BP) after ischemic stroke (IS) may follow various patterns. Post-event acute BP alterations mirror both stroke and patient characteristics, and resolve over time, yet their clinical significance is low or uncertain. Whether individual BP variations, based on a single standardized measurement normalized by a background BP course, have a distinct significance for stroke outcome remains unknown. We hypothesized that the BP difference index (BPD) between daytime supine resting and a series of surrounding BP values (daytime, 24-hour (24h)) in the subacute phase of IS is associated with functional outcome. Design and method: we included 131 IS patients [age 60.8 ± 12.5 years, median (NIHSS) score 5 (3-8)]. Office BP measurements and continuous 24-hour BP monitoring were performed on day 7 after stroke onset. The daytime period was defined as the interval from 6 a.m. to 10 p.m. Functional outcome was evaluated 90 days after stroke using the modified Rankin Scale (mRS) with an mRS score of 3 to 6 (dependency or death) considered as a poor outcome. Results: In a univariate analysis, high BPD was significantly associated with a poor stroke outcome (p = 0.001, 0.003, and 0.002 for systolic, diastolic, and mean BP, respectively, irrespective of the normalization subperiod (daytime, 24h). In a multivariate analysis, the predictive value of BPD remained significant only for systolic BP [SBP] normalized by daytime or 24h mean (OR, 1.06; 95% CI, 1.01-1.11; p = 0.02) after adjustment for covariates. Moreover, the relationship was stronger in a subgroup of patients able to walk independently (mRS 0-2) on day 7 after stroke onset (adjusted OR, 1.08; 95% CI, 1.01-1.17; p = 0.049 for SBP normalized by daytime or adjusted OR, 1.09; 95% CI, 1.01-1.18; p = 0.03 for SBP normalized by 24h mean). Conclusions: We found that the higher difference between supine resting and daytime or diurnal mean BP in patients in the subacute phase of ischemic stroke is independently associated with a poor outcome. This BP index might be useful in clinical practice, including therapeutic decisions, but needs broader studies in patient populations of stroke subtypes.

Seasonal variation of ambulatory blood pressure in Chinese hypertensive adolescents.

Blood pressure (BP) exhibits seasonal variation with lower levels at higher temperatures and vice versa. This phenomenon affects both sexes and all age groups. So far, only a few research studies have investigated this condition in adolescents and none of them were based on hypertensive population or ever applied ambulatory blood pressure monitor (ABPM). Therefore, we carried out the first study that used ABPM to record seasonal variation of blood pressure in hypertensive adolescents. From March 2018 to February 2019, 649 ABPMs from hypertensive adolescents between 13 and 17 years who were referred to wear an ABPM device in Beijing and Baoding were extracted. Seasonal change in ambulatory BP value, dipping status, and prevalence of different BP phenotypes were analyzed and compared. Mean age of participants was 14.9 ± 1.5 years and 65.8% of them were boys. Of the participants, 75.3% met the criteria of overweight or obesity. From summer to winter, average 24-hour, day-time, and night-time BP showed significant rise, which was 9.8/2.8, 9.8/3.0, and 10.9/3.4 mmHg, respectively. This seasonal effect on BP was not dependent on the obesity degree. In addition, higher prevalence of nondippers and risers existed in winter while white coat hypertension was more frequent in warmer seasons. Hypertensive adolescents showed evident seasonal change in their ABPM results, which was featured by elevated BP level and more frequent abnormal dipping patterns in winter. On the contrary, higher prevalence of white coat hypertension was found in warmer seasons. Physicians should take seasonal variation into consideration when managing adolescent hypertension.

Novel insights into the association between seasonal variations, blood pressure, and blood pressure variability in patients with new-onset essential hypertension

BackgroundBlood pressure (BP) exhibits seasonal variations, with peaks reported in winter. However, the association between seasonal variations and blood pressure variability in patients with new-onset essential hypertension is not fully understood. This study evaluated the potential association of seasonal variations with new-onset essential hypertension.MethodsThis retrospective observational study recruited a total of 440 consecutive patients with new-onset essential hypertension who underwent 24-h ambulatory electrocardiograph (ECG) and BP measurement at our department between January 2019 and December 2019. Demographic and baseline clinical data including BP variability, heart rate variability, and blood tests were retrieved. Multivariate linear regression analysis was performed to identify factors independently associated with mean BP and BP variability.ResultsAmong the 440 patients recruited, 93 cases were admitted in spring, 72 in summer, 151 in autumn, and 124 in winter. Univariate analysis revealed that systolic BP (SBP), diastolic BP (DBP), high-sensitivity C-reactive protein, SBP drop rate, DBP drop rate, 24-h standard deviation of SBP, 24-h standard deviation of DBP, 24-h SBP coefficient of variation, and 24-h DBP coefficient of variation were associated with patients admitted in winter (P < 0.05 for all). Multivariate linear regression analysis showed that winter was the influencing factor of 24-h standard deviation of SBP (B = 1.851, t = 3.719, P < 0.001), 24-h standard deviation of DBP (B = 1.176, t = 2.917, P = 0.004), 24-h SBP coefficient of variation (B = 0.015, t = 3.670, P < 0.001), and 24-h DBP coefficient of variation (B = 0.016, t = 2.849, P = 0.005) in hypertensive patients.ConclusionsSeasonal variations are closely associated with BP variability in patients with new-onset essential hypertension. Our study provides insight into the underlying pathogenesis of new-onset essential hypertension.

Elevated shock index and modified shock index are associated with mortality and major adverse cardiac events in patients with acute myocardial infarction: A systematic review and meta-analysis

Background Blood pressure (BP) and heart rate (HR) have been studied extensively to predict unfavourable outcomes in patients suffering from an acute myocardial infarction (AMI). Shock index (SI) and modified shock index (MSI) are two new emerging parameters that incorporate BP and HR into their calculations, thereby improving the predictive value of each HR and BP alone in AMI patients. Thus, our aim was to determine the prognostic utility of SI and MSI in AMI patients. Methods We searched PubMed, ProQuest, EBSCO Host, and Europe PMC from conception to May 2022. Studies were eligible if they evaluated the relationship of SI and MSI with all-cause mortality and major adverse cardiac events. Results A total of 16 studies involving 80,195 participants met the inclusion criteria and were included in this meta-analysis. Our study revealed significantly higher all-cause mortality risk for patients with high SI and MSI compared to patients with low indices, regardless of the periods of outcomes, study population, or diverse cut-off values. Moreover, both increased SI and MSI also predicted higher major adverse cardiac event rates. Conclusions According to our findings, both SI and MSI in the emergency department can predict all-cause mortality and major adverse cardiac events in patients with acute myocardial infarction. Given this growing body of evidence, as well as the fact that SI and MSI are very simple objective indices derived from two readily available vital signs, they should be used in daily clinical practice to risk stratify patients presenting with acute myocardial infarction. PROSPERO registration CRD42022329558.

Elevated shock index and modified shock index are associated with mortality and major adverse cardiac events in patients with acute myocardial infarction: A systematic review and meta-analysis

Background Blood pressure (BP) and heart rate (HR) have been studied extensively to predict unfavourable outcomes in patients suffering from an acute myocardial infarction (AMI). Shock index (SI) and modified shock index (MSI) are two new emerging parameters that incorporate BP and HR into their calculations, thereby improving the predictive value of each HR and BP alone in AMI patients. Thus, our aim was to determine the prognostic utility of SI and MSI in AMI patients. Methods We searched PubMed, ProQuest, EBSCO Host, and Europe PMC from conception to May 2022. Studies were eligible if they evaluated the relationship of SI and MSI with all-cause mortality and major adverse cardiac events. Results A total of 16 studies involving 80,195 participants met the inclusion criteria and were included in this meta-analysis. Our study revealed significantly higher all-cause mortality risk for patients with high SI and MSI compared to patients with low indices, regardless of the periods of outcomes, study population, or diverse cut-off values. Moreover, both increased SI and MSI also predicted higher major adverse cardiac events rates. Conclusions According to our findings, both SI and MSI in the emergency department can predict all-cause mortality and major adverse cardiac events in patients with acute myocardial infarction. Given this growing body of evidence, as well as the fact that SI and MSI are very simple objective indices derived from two readily available vital signs, they should be used in daily clinical practice to risk stratify patients presenting with acute myocardial infarction. PROSPER registration CRD42022329558.

Blood pressure response to commonly administered antihypertensives for severe inpatient hypertension.

BackgroundBlood pressure (BP) elevations are commonly treated in hospitalized patients; however, treatment is not guideline directed. Our objective was to assess BP response to commonly prescribed antihypertensives after the development of severe inpatient hypertension (HTN).MethodsThis is a cohort study of adults, excluding intensive care unit patients, within a single healthcare system admitted for reasons other than HTN who developed severe HTN (systolic BP>180 or diastolic BP >110 mmHg at least 1 hour after admission). We identified the most commonly administered antihypertensives given within 6 hours of severe HTN (given to >10% of treated patients). We studied the association of treatment with each antihypertensive vs. no treatment on BP change in the 6 hours following severe HTN development using mixed-effects model after adjusting for demographics and clinical characteristics.ResultsAmong 23,147 patients who developed severe HTN, 9,166 received antihypertensive treatment. The most common antihypertensives given were oral metoprolol (n = 1991), oral amlodipine (n = 1812), oral carvedilol (n = 1116), IV hydralazine (n = 1069) and oral hydralazine (n = 953). In the fully adjusted model, treatment with IV hydralazine led to 13 [-15.9, -10.1], 18 [-22.2, -14] and 11 [-14.1, -8.3] mmHg lower MAP, SBP, and DBP in the 6 hours following severe HTN development compared to no treatment. Treatment with oral hydralazine and oral carvedilol also resulted in significantly lower BPs in the 6 hours following severe HTN development (6 [-9.1, -2.1 and -7 [-9.1, -4.2] lower MAP, respectively) compared to no treatment. Receiving metoprolol and amlodipine did not result in a drop in BP compared to no treatment.ConclusionAmong commonly used antihypertensives, IV hydralazine resulted in the most significant drop in BP following severe HTN, while metoprolol and amlodipine did not lower BP. Further research to assess the effect of treatment on clinical outcomes and if needed which antihypertensives to administer are necessary.

Prognostic Value of Time in Blood Pressure Target Range Among Patients With Heart Failure

BackgroundBlood pressure (BP) is a continuous and dynamic measure. However, standard BP control metrics may not reflect the variability in BP over time. ObjectivesThis study assessed the prognostic value of time in BP target range among hypertensive patients with heart failure (HF). MethodsThe authors performed a post hoc analysis of data from the TOPCAT (Treatment of Preserved Cardiac Function HF with an Aldosterone Antagonist) trial and the BEST (Beta-Blocker Evaluation of Survival Trial). Time in target range (TTR) for each patient was calculated using linear interpolation across the study period with the target range of systolic BP between 120 and 130 mm Hg. ResultsA total of 4,789 hypertensive patients (n = 1,654 from BEST and n = 3,135 from TOPCAT) were included. The cumulative incidences of primary endpoint (ie, cardiovascular death or HF hospitalization) were highest among the top quartile of TTR with a dose-dependent manner across quartiles (Ptrend <0.005). The top quartile of TTR was significantly associated with a lower risk of primary outcome using adjusted Cox regression model (HR: 0.71; 95% CI: 0.60-0.82), cardiovascular mortality (HR: 0.68; 95% CI: 0.55-0.84), HF hospitalization (HR: 0.70; 95% CI: 0.58-0.85), all-cause mortality (HR: 0.69; 95% CI: 0.58-0.83), and any hospitalization (HR: 0.76; 95% CI: 0.67-0.85). Further analyses using restricted cubic spline indicated a linear relationship between TTR and primary outcome. Similar patterns were observed in the individual trial. Sensitivity analyses generated consistent results while redefining target range as 110 to 130 mm Hg for systolic BP or 70 to 80 mm Hg for diastolic BP. ConclusionsTTR could independently predict major adverse cardiovascular events in hypertensive patients with HF.

Blood Pressure and Cardiovascular Disease in Older Patients With Diabetes: Retrospective Cohort Study.

BackgroundBlood pressure (BP) targets in elderly patients with diabetes remain unclear. We evaluated the association between BP and cardiovascular disease in elderly patients with diabetes without cardiovascular disease or heart failure.Methods and ResultsWe performed a retrospective cohort study of 225 563 elderly (aged ≥65 years) patients with diabetes without cardiovascular disease or heart failure from 2009 to 2017 using the National Health Information Database. We divided the participants by systolic BP (SBP) and diastolic BP. Primary composite outcomes were stroke, myocardial infarction, heart failure, and all‐cause death analyzed by Cox proportional hazards regression analysis adjusted for baseline covariates. During a median follow‐up of 7.76 years, the incidence rate of primary composite outcomes was 26.62 per 1000 person‐years. In multivariable Cox proportional hazard modeling, the risk of the primary outcome had a U‐curved association with SBP/diastolic blood pressure with a nadir between 120 and 129 mm Hg/65 and 69 mm Hg, respectively. Hypertension medication was associated with lower risk of primary composite outcomes in SBP ≥140 mm Hg (P for interaction for SBP <0.001) and diastolic blood pressure ≥90 mm Hg (P for interaction for diastolic blood pressure=0.018). In participants aged ≥80 years, SBP ≥160 mm Hg was only a marginally higher risk for primary composite outcomes (hazard ratio=1.11; 95% CI, 0.98–1.24).ConclusionsIn this large sample of older Korean patients with diabetes, cardiovascular events were more common in people with resting SBP or diastolic BP ≥140 or 95 mm Hg, respectively, and also more common in people with resting SBP or diastolic BP <120 or 65 mm Hg, respectively.

Heritability and genome-wide association study of blood pressure in Chinese adult twins.

BackgroundBlood pressure (BP) is an independent and important factor for chronic diseases such as cardiovascular diseases and diabetes.MethodsWe firstly conducted twin modeling analyses to explore the heritability of BP, including systolic blood pressure (SBP), diastolic blood pressure (DBP), pulse pressure (PP) and mean arterial pressure (MAP), and then performed genome‐wide association studies to explore the associated genomic loci, genes, and pathways.ResultsA total of 380 Chinese twin pairs were included. The AE model containing additive genetic parameter (A) and unique/non‐shared environmental parameter (E) was the best fit model, with A accounting for 53.7%, 50.1%, 48.1%, and 53.3% for SBP, DBP, PP and MAP, respectively. No SNP was found to reach the genome‐wide significance level (p < 5 × 10−8), however, three, four, 14 and nine SNPs were found to exceed suggestive significance level (p < 1 × 10−5) for SBP, DBP, PP, and MAP, respectively. And after imputation, 46, 37, 91 and 61 SNPs were found to exceed the suggestive significance level for SBP, DBP, PP, and MAP, respectively. In gene‐based analysis, 53 common genes were found among SBP, DBP, PP, and MAP. In pathway enrichment analysis, 672, 706, 701, and 596 biological pathways were associated with SBP, DBP, PP, and MAP, respectively (p < 0.05).ConclusionOur study suggests that BP is moderately heritable in the Chinese population and could be mediated by a series of genomic loci, genes, and pathways. Future larger‐scale studies are needed to confirm our findings.

Effects of intensive blood pressure control on mortality and cardiorenal function in chronic kidney disease patients

Background Blood pressure (BP) variability is highly correlated with cardiovascular and kidney outcomes in patients with chronic kidney disease (CKD). However, appropriate BP targets in patients with CKD remain uncertain. Methods We searched PubMed, Embase, and the Cochrane Library for randomized controlled trials (RCTs) of CKD patients who underwent intensive BP management. Kappa score was used to assess inter-rater agreement. A good agreement between the authors was observed to inter-rater reliability of RCTs selection (kappa = 0.77; P = 0.005). Results Ten relevant studies involving 20 059 patients were included in the meta-analysis. Overall, intensive BP management may reduce the incidence of cardiovascular disease mortality (RR: 0.69, 95% CI: 0.53 to 0.90, P: 0.01), all-cause mortality (RR: 0.77, 95% CI: 0.67 to 0.88, P < 0.01) and composite cardiovascular events (RR: 0.84 95% CI: 0.75 to 0.95, P < 0.01) in patients with CKD. However, reducing BP has no significant effect on the incidence of doubling of serum creatinine level or 50% reduction in GFR (RR: 1.26, 95% CI: 0.66 to 2.40, P = 0.48), composite renal events (RR 1.07, 95% CI: 0.81 to 1.41, P = 0.64) or SAEs (RR: 0.97, 95% CI: 0.90 to 1.05, P = 0.48). Conclusion In patients with CKD, enhanced BP management is associated with reduced all-cause mortality, cardiovascular mortality, and incidence of composite cardiovascular events.

Impact of Blood Pressure Visit-to-Visit Variability on Adverse Events in Patients With Nonvalvular Atrial Fibrillation: Subanalysis of the J-RHYTHM Registry.

BackgroundBlood pressure (BP) variability has reportedly been a risk factor for various clinical events. To clarify the influence of BP visit‐to‐visit variability on adverse events in patients with nonvalvular atrial fibrillation, a post hoc analysis of the J‐RHYTHM Registry was performed.Methods and ResultsOf 7406 outpatients with nonvalvular atrial fibrillation from 158 institutions, 7226 (age, 69.7±9.9 years; men, 70.7%), in whom BP was measured 4 times or more (14.6±5.0 times) during the 2‐year follow‐up period or until occurrence of an event, constituted the study group. SD and coefficient of variation of BP values were calculated as BP variability. Thromboembolism, major hemorrhage, and all‐cause death occurred in 110 (1.5%), 121 (1.7%), and 168 (2.3%) patients, respectively. When patients were divided into quartiles of systolic BP‐SD (<8.20, 8.20–10.49, 10.50–13.19, and ≥13.20 mm Hg), hazard ratios (HRs) for all adverse events were significantly high in the highest quartile compared with the lowest quartile (HR, 2.00, 95% CI, 1.15–3.49, P=0.015 for thromboembolism; HR, 2.60, 95% CI, 1.36–4.97, P=0.004 for major hemorrhage; and HR, 1.85, 95% CI, 1.11–3.07, P=0.018 for all‐cause death) after adjusting for components of the CHA2DS2‐VASc score, warfarin and antiplatelet use, atrial fibrillation type, BP measurement times, and others. These findings were consistent when BP‐coefficient of variation was used instead of BP‐SD.ConclusionsSystolic BP visit‐to‐visit variability was significantly associated with all adverse events in patients with nonvalvular atrial fibrillation. Further studies are needed to clarify the causality between BP variability and adverse outcomes in patients with nonvalvular atrial fibrillation.RegistrationURL: https://www.umin.ac.jp/ctr/; Unique Identifier: UMIN000001569.

English

BACKGROUND Blood pressure (BP) in the right and left arms can be different. This inter arm difference (IAD) in BP can be systolic (IAD - SBP) and / or diastolic (IAD - DBP). IAD of ≥ 10 mm of Hg is considered significant. SYNTAX score is used to assess the complexity of coronary artery lesions. Prevalence of IAD in patients undergoing coronary angiography (CAG) and its relationship to complexity of coronary artery disease is unclear. METHODS In 100 patients taken up for CAG, BP was recorded in both the arms simultaneously with automated devices using oscillometric method. Significant IAD was defined as ≥ 10 mm of Hg. Using SYNTAX score, patients were divided into two groups; those with a lower score &lt; 22 and those with a higher score ≥ 22. Data was analysed using SPSS version 16. Mean difference of the variables was analysed using Independent t test. Association of interarm BP difference and high SYNTAX score was analysed using Chi Square test. RESULTS Significant IAD of ≥ 10 mm of Hg was noted in 16 out of 100 patients. SYNTAX score of ≥ 22 was seen in 30 patients. IAD - SBP ≥ 10 was noted in 23.3 % in patients with higher SYNTAX score as against 2.9 % in those with lower score (p 0.001). IAD - DBP ≥ 10 was seen in 20 % of patients with higher SYNTAX score as against 1.4 % in those with lower SYNTAX score (p 0.001). CONCLUSIONS Interarm blood pressure difference of ≥ 10 mm of Hg is seen in 16 % of cases taken up for coronary angiogram. Patients with IAD ≥ 10 mm of Hg had higher SYNTAX score of ≥ 22 suggesting more complex coronary artery disease. KEYWORDS Interarm Blood Pressure Difference, SYNTAX Score

Identification of blood pressure reflecting personalized traits using bilateral photoplethysmography

BACKGROUND: Blood pressure (BP) is currently diagnosed by cuff-based devices, which are inconvenient and provide discontinuous measurements. Photoplethysmography (PPG)-based cuffless techniques have recently been used to accurately estimate both systolic BP (SBP) and diastolic BP (DBP). However, it is difficult to use these SBP and DBP estimations to reflect the personalized traits in the peripheral vascular condition; thus, their accuracy is limited.OBJECTIVE: The purpose of this study is to describe a technique that can be distinguished simply among three BP categories (normotensive, prehypertensive, and hypertensive) and reflect individual traits using PPG only.METHODS: We measured BP over 120 s using the fingers of 105 subjects. The PPG waveforms varied in size and amplitude over time. Therefore, normalization for uniform features for individual traits was done after the extracted waveforms were divided into multiple windows. The feature is determined by the lowest amplitude in the waveform within each divided window. The features have been applied to distinguish three BP categories using the first-eigenvector (1-EV) and second-eigenvector (2-EV) in linear discriminant analysis.RESULTS: The best decision boundary for each BP category was estimated using 1-EV (0.02 to 0.02) and 2-EV (0.02) in the hypertensive category, 1-EV ( 0) and 2-EV (0.02) in the prehypertensive category, and 1-EV (0.02) and 2-EV (0.02) in the normotensive category. The overlap range with 1-EV (0.02 to 0) and 2-EV (0.02) in particular accurately reflected individual traits.CONCLUSION: Discrimination among the three BP categories reflecting individual traits was successfully achieved using PPG. This method could improve limitations of cuff-based techniques.

An Evaluation of Racial Differences in the Classification of Blood Pressure Control after Stroke

Background Blood pressure (BP) control is important for secondary stroke prevention and there are racial differences in BP control after stroke. BP is often treated based on in-clinic BP measurement; however, casual BP obtained in clinic may be inaccurate. We sought to determine whether race was associated with BP control misclassification in stroke survivors. Methods We followed ischemic/hemorrhagic stroke and transient ischemic attack patients in clinic within 30 days of hospital discharge. Sitting BP was obtained using a standard office automated machine (casual BP). BP was also measured with an automated office BP machine (AOBP), which measures 6 unattended BPs and averages the last 5. OABP has been used to approximate the gold standard 24-hour ambulatory BP (office BP 140/90 = AOBP 135/85). We defined the following categories: concordant control (AOBP Results Among 216 patients, mean age was 59.5 (SD 12.9); 50.5% African American, 21.3% Hispanic (HIS), and 25.5% Non-Hispanic White (NHW). BP control was misclassified in 32.1% of African Americans (17% pseudo-resistant and 16.5% masked uncontrolled); 26.1% of HIS (8.7% and 17.4%); and 20% of NHW (18.2% and 1.8%). In the univariate analysis, there was a trend toward an association between race and BP category (p = 0.06). Race was significantly associated with misclassification in the regression analysis. The odds ratio for masked uncontrolled compared to concordant controlled BP was 12.2 (95% CI 1.5, 99.2) for AA compared to NHW and 9.9 (95% CI 1.1, 87.4) for HIS compared to NHW. Conclusion These findings highlight the challenges in classifying control of BP and thus appropriately treating hypertension after stroke. Accurate tools for BP measurement including AOBP, home BP, and ambulatory BP monitoring should be utilized to optimize BP treatment after stroke.

Once versus twice daily antihypertensive medications for the control of nocturnal blood pressure: a comparative study

BackgroundBlood pressure (BP) shows short-term variability within the 24 h, which can only be assessed with 24-h ambulatory blood pressure monitoring (ABPM). It is of utmost importance to control BP throughout the night to reduce incidence of hypertension complications. The purpose of this study is to evaluate the effect of timing and frequency of antihypertensive medications on the average nighttime and 24-h blood pressure control.ResultsThe study enrolled 199 hypertensive patients with controlled office blood pressure; 135 (67.8%) patients were on once daily antihypertensive medication (group 1) while 64 (32.2%) patients were on twice daily doses (group 2). The mean office SBP was 128.7 ± 7.8 mmHg in group 1 vs 129.6 ± 6.6 mmHg in group 2, (p = 0.421). ABPM readings for both groups were as follows: mean daytime SBP was 125.4 ± 11.6 mmHg vs 130.1 ± 12.9, p = 0.011; mean nighttime SBP was 117.0 ± 12.4 mmHg vs 123.1 ± 13.9 mmHg, p = 0.002, and mean 24-h SBP was 122.7 ± 10.6 mmHg vs 127.5 ± 12.0, p = 0.005. The prevalence of non-dipping was 68.9% in group 1 vs 70.3% in group 2 patients, p = 0.8 (the mean dipping ratio was 0.93 ± 0.08 in group 1 vs 0.95 ± 0.07 in group 2, p = 0.198). The prevalence of masked hypertension was higher in group 2 (28.1% vs 43.8%, p = 0.029).ConclusionTaking an extra antihypertensive pill at night did not show a decrease in the nighttime or the average 24H blood pressure in hypertensive patients with controlled office BP. On the contrary, patients who used twice daily antihypertensive medications seem to have higher nighttime and 24-h SBP, although the dipping ratio was comparable in both groups.

Age-period-cohort projection of trends in blood pressure and body mass index in children and adolescents in Hong Kong

BackgroundBlood pressure (BP) and body mass index (BMI) trends during childhood and adolescence are complex, making context-specific projections necessary to inform prevention and presage changes.ObjectiveThis study aimed to project BP and BMI in Hong Kong Chinese children and adolescents from 2015 to 2024 based on trends in BP and BMI observed from 1996/99 to 2014.MethodsWe decomposed recent trends into sex-specific contributions of age, period and cohort using age-period-cohort linear regression with Bayesian inference and autoregressive priors based on BP in children and adolescents aged 9–18 years from 1999 to 2014 and BMI in those aged 6–18 years from 1996 to 2014. We then used the resultant models to project BP and BMI from 2015 to 2024.ResultsDuring the study period, systolic BP decreased from 1999 to 2004/5 before gradually increasing to 2014 during childhood (for boys: from 104.6 to 101.9 and then to 103.4 mmHg) and during adolescence. Similar patterns were observed for diastolic BP. BMI generally increased from 1996 to 2009 before falling to 2014 during childhood (e.g. for boys: from 17.2 to 18.0 and then to 17.1 kg/m2). From 2015 onwards, systolic BP was projected to increase in girls, but remain stable in boys. For both sexes, diastolic BP was projected to increase, whereas BMI was projected to decrease to 2024.ConclusionsIn this economically developed Chinese setting, future trends in BP and BMI in children and adolescents are predicted to be divergent, consistent with prior discordant trends in BP and BMI.

Lower Blood Pressure After Transcatheter or Surgical Aortic Valve Replacement is Associated with Increased Mortality

BackgroundBlood pressure (BP) guidelines for patients with aortic stenosis or a history of aortic stenosis treated with aortic valve replacement (AVR) match those in the general population, but this extrapolation may not be warranted.Methods and ResultsAmong patients enrolled in the Medtronic intermediate, high, and extreme risk trials, we included those with a transcatheter AVR (n=1794) or surgical AVR (n=1103) who were alive at 30 days. The associations between early (average of discharge and 30 day post‐AVR) systolic BP (SBP) and diastolic BP (DBP) measurements and clinical outcomes between 30 days and 1 year were evaluated. Among 2897 patients, after adjustment, spline curves demonstrated an association between lower SBP (<120 mm Hg, representing 21% of patients) and DBP (<60 mm Hg, representing 30% of patients) and increased all‐cause and cardiovascular mortality and repeat hospitalization. These relationships were unchanged when patients with moderate‐to‐severe aortic regurgitation post‐AVR were excluded. After adjustment, compared with DBP 60 to <80 mm Hg, DBP 30 to <60 mm Hg was associated with increased all‐cause (adjusted hazard ratio 1.62, 95% CI 1.23–2.14) and cardiovascular mortality (adjusted hazard ratio 2.13, 95% CI 1.52–3.00), but DBP 80 to <100 mm Hg was not. Similarly, after adjustment, compared with SBP 120 to <150 mm Hg, SBP 90 to <120 mm Hg was associated with increased all‐cause (adjusted hazard ratio 1.63, 95% CI 1.21–2.21) and cardiovascular mortality (adjusted hazard ratio 1.81, 95% CI 1.25–2.61), but SBP 150 to <180 mm Hg was not.ConclusionsLower BP in the first month after transcatheter AVR or surgical AVR is common and associated with increased mortality and repeat hospitalization. Clarifying optimal BP targets in these patients ought to be a priority and may improve patient outcomes.Clinical Trial Registration InformationURL: http://www.clinicaltrials.gov. Unique identifiers: NCT01586910, NCT01240902.