Postoperative hypotension in patients recovering from noncardiac surgery: a prospective, blinded observational study.

Intra-operative hypotension is common during caesarean section and may result in adverse maternal effects, such as nausea and vomiting. While oscillometric blood pressure and continuous non-invasive arterial pressure monitoring enable reactive treatment, the hypotension prediction index offers a machine learning-based approach that may allow proactive haemodynamic intervention. This study investigated whether hypotension prediction index-guided management could reduce the incidence of intra-operative hypotension compared with oscillometric and continuous non-invasive arterial pressure monitoring. Patients scheduled for elective caesarean section under spinal anaesthesia were allocated randomly to one of three haemodynamic monitoring strategies: oscillometric blood pressure; continuous non-invasive arterial pressure; or hypotension prediction index-guided monitoring. Hypotension and hypertension were defined as mean arterial pressure < 65 mmHg and ≥ 100 mmHg, respectively. Hypotension was treated using intermittent intravenous boluses of noradrenaline. The primary outcome was the time-weighted average of hypotension. Secondary outcomes included time-weighted average hypertension and maternal adverse effects, including bradycardia, nausea and vomiting. Data from 171 patients were analysed. Median time-weighted average hypotension was significantly higher in patients allocated to the oscillometric and continuous non-invasive arterial pressure groups compared with the hypotension prediction index group (0.89 mmHg and 0.30 mmHg vs. 0.08 mmHg, respectively, p < 0.001). Patients allocated to the oscillometric group had a higher incidence of maternal nausea and vomiting compared with those allocated to the continuous non-invasive arterial pressure and hypotension prediction index groups (nausea: 43/59 vs. 29/55 and 30/57, respectively, p = 0.038; and vomiting: 13/59 vs. 6/55 and 3/57, respectively, p = 0.023). Hypotension prediction index-guided management during caesarean section significantly reduced intra-operative hypotension without increasing the risk of hypertension. This approach provides a proactive strategy for haemodynamic optimisation in obstetric anaesthesia.

Nocturnal hypertension is the blood pressure (BP) phenotype most strongly associated with cardiovascular morbidity and mortality, yet no specific therapeutic strategy has been established. Physical activity effectively lowers BP, but the impact of different exercise modalities on nocturnal BP remains unclear. In this randomized clinical trial, 66 patients with nocturnal hypertension were assigned to 12 weeks of supervised high-intensity interval training (HIIT, n = 38) or isometric resistance training (IRT, n = 28). The primary outcome was the change in nocturnal SBP measured by ambulatory blood pressure monitoring (ABPM). Fourteen participants (21%) did not complete the intervention, leaving 52 patients (73% women; mean age 49 ± 12 years; BMI 33 ± 7 kg/m 2 ) for analysis. Exercise training significantly reduced office BP (-5.8 ± 18/-3.6 ± 10 mmHg, P < 0.05) and 24-h ABPM (-4.2 ± 12/-2.9 ± 7 mmHg, P < 0.05), mainly driven by nocturnal BP reductions (-6.9 ± 12/-4.7 ± 7 mmHg, both P < 0.001). The HIIT group showed a significantly greater decrease in nocturnal SBP compared with IRT (-9.8 ± 12.3 vs. -2.7 ± 10.4 mmHg, P < 0.001). After adjustment by sex, BMI, age, and antihypertensive treatment, HIIT lowered nocturnal systolic ABPM by -7.5 ± 3.3 mmHg (95% CI: -14.2 to -0.8; P = 0.030) more than IRT. Supervised exercise training, particularly HIIT, significantly lowers nocturnal BP in patients with nocturnal hypertension, regardless of weight loss. These findings suggest HIIT as a promising nonpharmacological therapeutic option for this high-risk phenotype.

Clinical significance of fragmented QRS in isolated hypertension: Associations with ventricular arrhythmia burden and autonomic dysfunction.

Nocturnal hypertension is closely associated with left ventricular hypertrophy (LVH) in patients with chronic kidney disease (CKD). Recently, several studies have shown that central pressure reflects the actual load on the cardiovascular system. However, the relationship between nighttime central systolic blood pressure (SBP) and LVH in CKD patients remains unknown. A total of 3198 non-dialysis CKD patients were enrolled in this multicenter retrospective study. Ambulatory blood pressure monitoring was performed using the Mobil-O-Graph PWA device. Applying 120/130 mm Hg as the nighttime brachial SBP (bSBP)/central SBP with c2 calibration (c2SBP) thresholds, patients were classified into 4 nocturnal hypertension patterns. Logistic regression and the net reclassification improvement were used to analyze the associations between nocturnal SBP indices and LVH. There were 989 patients (30.9%) who had nocturnal central hypertension, and 448 patients (15%) had LVH. As renal function declined, the incidence of both LVH and nocturnal hypertension demonstrated a significant ascending trend. In addition, LVH risk increased progressively with higher nighttime c2SBP levels. Multivariate logistic regression and net reclassification improvement analyses suggested that nighttime c2SBP demonstrated superior correlation with LVH compared to nighttime bSBP. With consistent nocturnal normotension as the reference, the adjusted odds ratios were 1.183 (95% CI: 0.816-1.715, P = .377) for isolated nocturnal brachial hypertension and 2.660 (95% CI: 2.051-3.449, P < .001) for consistent nocturnal hypertension, respectively. Nighttime central SBP is more closely associated with LVH in non-dialysis CKD patients, and further prospective studies are needed to validate its prognostic value.

Large language models have emerged as potential tools to support hypertension care, including diagnosis, treatment decision-making, and patient education. However, evidence regarding their validity, performance, and clinical applicability remains limited. The objective is to map current applications of large language models in hypertension care, with emphasis on model optimization strategies, evaluation approaches, and reported limitations. We conducted a Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews-compliant scoping review of primary studies published between 2023 and 2025 evaluating large language models in hypertension. Thirty-three studies were included. Data were charted on clinical use cases, model optimization techniques, evaluation metrics, data sets, and limitations. Applications were categorized into clinical decision support systems, patient education, medical education, research support, and administrative functions. GPT-based models predominated (82%). Model optimization was limited: 89% relied exclusively on prompt engineering. Most applications focused on patient education (52%) and clinical decision support systems (24%). In clinical decision support systems, reported accuracy ranged from 65% to 100%, reaching 87% to 91% for ambulatory blood pressure monitoring interpretation. Patient education applications showed accuracy between 80% and 90%, but frequent issues included excessive language complexity and occasional unsafe outputs. Across domains, evaluation methods were heterogeneous, reproducibility was inconsistently assessed, and safety concerns, including hallucinations and outdated knowledge, were commonly reported. Current evidence suggests that large language models may support selected tasks in hypertension care; however, their clinical reliability remains uncertain. The limited methodological rigor, minimal use of advanced optimization techniques, and narrow scope of evaluated applications preclude conclusions regarding routine clinical use. Further rigorously designed studies are required before broader implementation can be considered.

LAST-CBPM: photoplethysmography-based quasi-continuous blood pressure monitoring algorithm

Ambulatory blood pressure monitoring (ABPM) is the gold-standard non-invasive test for diagnosing arterial hypertension; however, it remains understudied in pediatric heart transplant recipients (HTRs). We evaluated the role of ABPM in diagnosing and managing hypertension. We conducted a single-center retrospective evaluation of pediatric HTRs transplanted between 2010 and 2023 (inclusive) with ≥ 1 post-transplant ABPM. Clinic blood pressures (CBPs) temporally linked to each ABPM were used to categorize patients into blood pressure phenotypes: normotensive (including well-controlled hypertension, if on anti-hypertensive therapy), sustained, white coat (WCH), and masked hypertension (MH). Demographic, clinical, and echocardiographic characteristics were compared across hypertensive phenotypes, with longitudinal changes evaluated using serial ABPMs. Data were available for 33 pediatric HTRs (61% female [20/33], median age at first ABPM 7.3 [5.3-10.4] years, 0.7 [0.2-2.6] years post-transplant). At the initial ABPM, 82% (27/33) were normotensive and 18% (6/33) were hypertensive, with 79% (26/33) on ≥ 1 antihypertensive medication. Of those with hypertensive CBPs, 60% (6/10) had a normal ABPM indicating WCH. At subsequent ABPM, 48% (10/21) normotensive patients remained normotensive, while 43% (9/21) developed hypertension. Among the 6 patients with WCH, 5 (83%) developed subsequent hypertension by ABPM. Median left ventricular mass was higher in hypertensive patients (160.9 g, 64.3-172.3 g) compared with WCH (54.4 g, 36.9-100.7 g) and normotensive patients (66.9 g, 45.4-94.3 g) (p = 0.032). ABPM provides important hypertension insights for pediatric HTRs, especially with abnormal CBPs. Progression from WCH to manifest hypertension was common. ABPM should therefore be utilized prior to implementing or modifying anti-hypertensive therapy.

The risk of persistent multisystem dysfunction following multisystem inflammatory syndrome in children (MIS-C), a severe postviral complication of COVID-19, remains unknown. We investigated long-term outcomes in patients younger than 21years with MIS-C (n = 173) vs without MIS-C (n = 14 190) up to 4.5years after COVID-19 in the Montefiore Health System (March 2020 to August 2024). MIS-C status was based on International Classification of Diseases, Tenth Revision codes and Centers for Disease Control and Prevention and World Health Organization criteria. 1:2 propensity score matching and Cox proportional hazards regression with multivariable adjustment were performed. Compared with patients without, patients with MIS-C showed markedly higher risk of cardiovascular disorders (adjusted hazard ratio [aHR] = 13.88 [4.69-41.07], P < .001), hypertension (aHR = 8.86 [4.12-19.06], P < .001), gastrointestinal disorders (aHR = 9.48 [2.66-33.71], P < .001), respiratory disorders (aHR = 3.46 [2.21-5.42], P < .001), and neurological disorders (aHR = 2.02 [1.22-3.34], P = .007). Preexisting hypertension (9.25% of patients with MIS-C vs 6.94% of controls) significantly predicted cardiovascular, neurological, respiratory, and gastrointestinal outcomes. Each 1-year increase in age was associated with increased risk of shock (aHR = 1.06 [1.02-1.11]) and chronic kidney disease (CKD) (aHR = 1.06 [1.01-1.12]). Preexisting diabetes (1.73% of patients with MIS-C) was associated with a 49-fold increased risk of CKD. Kaplan-Meier analysis showed higher persistent risk in the MIS-C group across all outcomes, ranging from 6.8% for CKD to 35.2% for respiratory disorders. Sensitivity analysis using different definitions of MIS-C corroborated our main findings. MIS-C is associated with broad multisystem morbidity persisting years after acute COVID-19, challenging earlier reports of transient illness. Structured long-term follow-up, including routine blood pressure monitoring, neurological and mental-health screening, and cardiovascular and renal surveillance, with coordinated multidisciplinary care is warranted.

The relation between obesity and blood pressure (BP) is well known; however, its relationship with night-time BP and BP variability (BPV) has not been adequately examined. To examine the relationship between obesity and night-time BP/BPV. Data from 6,767 adults (46.4% males), aged 56.0 ±14.0, were collected during their visit to the Outpatient Hypertension Unit of a single institution and had valid ambulatory BP monitoring and anthropometric data. Body mass index (BMI) was estimated by weight and height measurements that took place at the office and categorized as normal weight [<25 kg/m2; 1,719 (25.4%)], overweight [25-29.9 kg/m2; 2,976 (43.0%)] or obesity [≥30 kg/m2; 2,072 (30.6%)]. Standard deviation (SD) and coefficient of variation (CV) of BP were used as indices of BPV. After adjusting for confounders, BMI was significantly related to night-time systolic (b=0.38, 95%CI: 0.31-0.46) and diastolic BP (b =0.10 95%CI: 0.05-0.015). Similarly, after adjusting for confounders, obesity was related to SD (b=0.25, 95%CI: 0.02-0.49) and CV (b = 0.23, 95%CI: 0.03-0.42) of night-time systolic BPV, while a similar pattern was found for diastolic BPV (p < 0.001). Restricted cubic spline models showed a significant joint effect of splines after adjusting for confounders, for all BPV indices (p< 0.05), but a trend for non-linearity found only for systolic BPV indices (χ2 = 3.74, p = 0.053 for SD and χ2 = 3.54, p = 0.060 for CV). In conclusion, the relationship between obesity and both nighttime BP and BPV provides new insights into the possible effects of obesity on the cardiovascular system.

To investigate the effects of a 13-week Pilates Method (PM) program, combining mat and apparatus-based exercises, on ambulatory blood pressure (BP), autonomic reflex regulation, and endothelial function in women with hypertension receiving pharmacological treatment. Twenty-eight women with hypertension (39-59 years) were randomized to a control group (CG, n = 14) or a Pilates group (PG, n = 14). The PG completed supervised PM sessions twice weekly, while the CG maintained usual care. Outcomes included ambulatory BP monitoring (24-h, daytime, and nighttime), heart rate variability (HRV), autonomic reflex tests (Valsalva ratio, deep breathing, HR and BP response to standing, and isometric handgrip), flow-mediated dilation (FMD), and circulating nitric oxide (NO) and nitric oxide synthase (NOS). Analyses were adjusted for baseline body weight. Significant Group × Time interactions were observed for all ambulatory BP parameters (all P ≤ 0.022, η2p = 0.19-0.31), with greater reductions in PG (e.g., 24-h SBP -10.3 mmHg, P = 0.009). Among autonomic reflex tests, only the deep breathing test demonstrated a significant interaction (P < 0.001, η2p = 0.61), whereas HRV indices did not change. FMD showed no time or interaction effects. NO decreased in the CG (P = 0.002) but remained stable in the PG, while NOS decreased in the PG (P < 0.001). A 13-week PM program was associated with reductions in ambulatory BP and enhanced autonomic reflex responsiveness in women with hypertension. PM appears to be a feasible and safe low-to-moderate-intensity adjunct to pharmacological treatment, with favorable hemodynamic effects.

Survival after acute aortic dissection (AAD) has improved substantially; however, optimal exercise prescription and blood pressure (BP) thresholds during cardiac rehabilitation (CR) remain unclear. Although current guidelines recommend CR after aortic repair, evidence-based BP thresholds are undefined. A systematic search of PubMed and the Cochrane Library identified 88 records. After screening and eligibility assessment, 27 studies were included. Eligible studies investigated exercise-based rehabilitation, early mobilization, or BP-guided exercise management in patients with Stanford type A or B aortic dissection. Data on exercise intensity, BP limits, monitoring strategies, safety outcomes, and functional recovery were extracted and narratively synthesized. Most studies were observational, with only one randomized controlled trial evaluating early goal-directed mobilization. Exercise intensity was typically prescribed as low-to-moderate and frequently constrained by systolic BP thresholds; however, reported upper limits were inconsistent and often not explicitly defined or evidence-justified. Continuous or intermittent BP monitoring was commonly employed in early phases. Across studies, exercise-based cardiac rehabilitation was not clearly associated with increased rates of re-dissection or major adverse events, and early mobilization was associated with improved activities of daily living and shorter functional recovery time. Of the 27 included studies, explicit systolic blood pressure thresholds for exercise were reported in fewer than one-third, and quantitative descriptions of aortic event rates were provided in only a minority, with most studies concluding safety based on qualitative assessments; however, the absence of reported events does not necessarily indicate evidence of safety. Exercise-based cardiac rehabilitation following aortic dissection appears feasible when conducted under BP-guided monitoring, with no clear signal of increased aortic risk reported in the available literature. However, the current evidence remains largely qualitative and heterogeneous, highlighting the need for standardized exercise intensity criteria and prospective studies to establish evidence-based rehabilitation strategies.

The ambulatory arterial stiffness ındex (AASI), derived from ambulatory blood pressure monitoring, functions as a straightforward surrogate marker for arterial stiffness. Vascular age, calculated utilizing the SCORE Project, has gained increasing prominence and accessibility as a tool for conveying cardiovascular (CV) risk and is progressively recognized as a surrogate marker for vascular biological aging. Our aim was to assess the association between the AASI and SCORE-derived vascular age in individuals without established CV disease. In this cross-sectional study, 276 patients (53.6% women) aged 40-65 years without CV, cerebrovascular disease, or diabetes mellitus were evaluated. AASI was calculated from 24-hour ambulatory blood pressure monitoring data, and vascular age was estimated using SCORE charts. The strength and independence of the association between the AASI and vascular age were evaluated using Pearson's correlation and multivariable linear regression analyses. The mean vascular age was 59.7 years and mean AASI was 0.39. AASI was significantly associated with vascular age (r = 0.529; P <0.001). In the multivariable analysis, a 0.1-unit increase in AASI corresponded to a 0.992-year increase in vascular age (P = 0.015), independent of age, metabolic syndrome, and left ventricular mass. AASI is significantly associated with SCORE-derived vascular age, highlighting its potential utility as a simple, non-invasive indicator of vascular biological aging and a valuable tool for early CV risk stratification in outpatient settings.

Commentary On Validating the accuracy of Omron HEM-790XT1 electronic blood pressure monitor in the general population according to AAMI/ESH/ISO (ISO 81060-2:2018 + AMD1:2020).

Rethinking ambulatory blood pressure monitoring: blood pressure variability as a window into frailty and aging.

Hypertension is a leading cause of cardiovascular morbidity and mortality. Individuals living in rural areas have a higher prevalence of hypertension and a lower prevalence of blood pressure control. Factors contributing to the increased hypertension prevalence in rural populations include shortages of health care professionals, limited access to transportation and longer travel distances to care, lower health literacy, socioeconomic factors, and reduced access to pharmacies. Approaches to addressing barriers to effective hypertension management include expanding rural telehealth services, deploying mobile units, leveraging pharmacists, implementing remote blood pressure monitoring, and engaging community health workers. Health services need to be culturally tailored and address the unique challenges faced by rural communities. Further research is needed to identify effective methods for addressing health disparities experienced by rural populations related to hypertension management.

Estimated pulse wave velocity (ePWV), an easy to calculate proxy of carotid to femoral PWV (cfPWV), can be derived from 24-hour blood pressure monitoring (24h-BPM). Its role in acute ischemic stroke (AIS) has not previously been investigated in large multinational datasets. A pooled individual patient data analysis from 13 cohorts across seven countries was conducted, including 2,933 AIS patients who underwent 24h-BPM during the hyperacute to subacute phase. ePWV was calculated using a validated equation. Associations with clinical characteristics, stroke severity, etiologic subtypes, and outcomes were assessed with logistic regression. The primary outcome was poor functional outcome at 90 days, defined as a modified Rankin Scale (mRS) >2. Patients with higher ePWV presented with more severe strokes (median NIHSS 7 vs. 3, P < .001) and had poorer outcomes both at 90 days (63.7% vs. 23.7%, P < .001) and discharge (61.9% vs 29.1%, P < .001). ePWV was associated with poor outcome at 90 days (aOR: 1.24, 95% CI: 1.05-1.45) and discharge (aOR: 1.26, 95% CI: 1.12-1.42), per 1 m/s increase in ePWV, after adjustment for conventional risk factors and stroke severity. In patients ≤50 years, ePWV was highest in those with small vessel disease (SVD), who also had more cardiovascular risk factors than other stroke subtypes. ePWV derived from 24h-BPM is a simple, widely applicable measure of vascular aging that is associated with functional outcome after AIS. The higher ePWV observed in young patients with SVD underscores a potential early arteriosclerotic burden in this subgroup.

Frailty is a common condition in older hypertensive adults, and it is associated with an increased risk of adverse outcomes. Blood pressure variability (BPV) is an independent cardiovascular risk factor, but its relationship with frailty remains poorly understood, especially in outpatients. We aimed to investigate the association between short‑term 24‑hour BPV and frailty in a cohort of older hypertensive outpatients. In this cross‑sectional study, 184 hypertensive outpatients aged at least 75 years underwent frailty assessment using a 40‑item frailty accumulation index derived from comprehensive geriatric assessment and 24‑hour ambulatory BP monitoring (ABPM). The participants were categorized as nonfrail, prefrail, or frail, and short‑term BPV was quantified using multiple indices. Multiple regression analysis was used to identify associations between BPV and frailty status, and adjusted β estimates were reported. Mean (SD) age of the participants was 81.76 (4.32) years, and 68% were women. Of the entire group, 63 patients (34.2%) were nonfrail, 79 (42.9%) prefrail, and 42 (22.8%) frail. Frailty directly correlated with nocturnal diastolic BPV. In adjusted analyses, nocturnal diastolic BP was strongly associated with frailty (β = 0.076; P = 0.04), and systolic dipping showed a marked negative association with the frailty index (β = -0.17; P = 0.04). Nocturnal but not diurnal BPV is associated with frailty in older hypertensive outpatients. These findings support the potential clinical value of BPV in geriatric care as a noninvasive marker of physiological vulnerability, easy to obtain whenever ABPM is required for hypertension management. Further studies are needed to clarify causality and define the potential of BPV assessment and modulation in older patients.

Few studies have assessed patient perception of the management of their hypertensionin Europe. We aimed to compare the attitudes, barriers, and expectations of patients receiving treatmentfor hypertension in 7 European countries. Cross‑sectional data were obtained between January and April 2023, usinga web‑based questionnaire translated into each country's official language and distributed in the Czech Republic, France, Germany, Italy, Poland, Spain, and the United Kingdom (UK). A total of 4001 treated hypertensive adults returned a valid questionnaire. Their mean (SD) age was 68.3 (9.2) years (median, 70 y), 59.7% were men, and 91% were treated for longer than 1 year. The participants from Poland and the Czech Republic had a more unfavorable cardiovascularrisk profile than those from other countries (P <0.001). Differences across the countries were found for lifestyle, medical, and emotional risk scores (P <0.001). A total median number of pills per day was 4 (range, 3-5/d; P <0.001 between countries) and 2 for antihypertensive drugs. The frequency of follow‑up visits per year was the highest in France and lowest in the UK (P <0.001). In all countries, 10%-20% of the participants expressed a wish for more information mainly on treatment, drug side effects, and hypertension complications. Nonintentional interruption of medications was the main cause of nonadherence. According to patients, the management of hypertension is highly variable in differentEuropean countries. Our survey identified features that could be improved, such as increasing the amount of information provided to the patients, empowering the patients through adequate home blood pressure monitoring, and supporting medication adherence.

Long COVID-19 is recognized as a condition associated with autonomic nervous system (ANS) dysfunction. However, quantitative evidence of its impact on heart rate variability (HRV) and blood pressure (BP) regulation during postural changes remains limited. This study assessed autonomic imbalance in post-COVID-19 patients by evaluating HRV and BP responses during tilt table testing, comparing long COVID-19 patients with healthy controls. A total of 61 participants were enrolled, 39 long COVID-19 patients (Study Group, SG) and 22 healthy controls (Control Group, CG). HRV was analyzed using time- and frequency-domain parameters. BP monitoring evaluated systolic, and diastolic blood pressure (SBP, and DBP respectively), and Pulse pressure (PP = SBP-DBP) was calculated for each phase. SG participants exhibited marked autonomic dysfunction during tilt. In the upright phase, they showed a significant increase in mean RR intervals (p = 0.0136), reduced normalized low-frequency (LF†) with p = 0.0316, increased normalized high-frequency (HF†) with p = 0.0315, and a decreased low-frequency/high-frequency (LF/HF) ratio (p = 0.0316), indicating a blunted sympathetic response and impaired autonomic adaptation to orthostatic stress. BP responses were also impaired: SG demonstrated attenuated changes in PP (ΔPP) when transitioning from the upright position to the recovery phase (p < 0.037). Within-group analysis confirmed persistent RR interval instability (p < 0.0001), incomplete normalization of LF and HF components (both p < 0.0001), and delayed recovery of PP after return to supine position. BP responses were also diminished: SG showed smaller ΔPP when moving from standing upright to the recovery phase (p < 0.037). Baroreflex sensitivity values did not differ between groups. Long COVID-19 patients display significant autonomic dysregulation, characterized by reduced HRV, abnormal BP responses. These findings highlight the value of tilt testing in uncovering hidden dysautonomia and support the need for targeted interventions, including pharmacologic modulation and long-term HRV/BP monitoring, to improve cardiovascular stability in long COVID-19.