Clinic Blood Pressure Monitoring Research Articles

Economic Impact of Ambulatory Blood Pressure Monitoring Compared With Clinical Blood Pressure Monitoring: A Simulation Model.

Ambulatory blood pressure monitoring (ABPM) is considered the gold standard for proper diagnosis of hypertension. Yet, access to ABPM in the U.S. is limited, and the extent of coverage by commercial health plans remains uncertain, potentially limiting access to ABPM among commercially insured patients. This study aims to assess the net cost impact of using ABPM in comparison to clinical blood pressure monitoring (CBPM) in the U.S. over a 5-year time period. Using a Markov Model, we estimate the 5-year cumulative cost impact of using ABPM to confirm a prior diagnosis of primary hypertension using CBPM to avoid treatment for white-coat hypertension (WCH) in a hypothetical cohort of 1000 patients from a U.S. healthcare system perspective. The probability and cost inputs for the model were derived from available literature. Base-case model parameters were varied to account for different scenarios. Base-case results indicate using ABPM instead of CBPM over 5 years saves a total of $348,028, reflecting an average per-person-per-year (PPPY) cost saving of $70. In sensitivity analyses, almost all cases reveal ABPM as a cost-saving approach compared to CBPM, with cost savings reaching up to $228 PPPY in the highest hypertension treatment cost model. Regression results reveal that ABPM was cost-saving compared to CBPM if ABPM annual payment rates are $100 or less and annual hypertension treatment costs are ⩾$300. The potential cost-savings of using ABPM instead of CBPM found in our simulation model underscores the need for confirmatory research using real-world data to support increased use of ABPM as the standard diagnostic approach for hypertension.

Δ BP-Net: Monitoring "Changes" in Blood Pressure Using PPG with Self-contrastive Masking.

Estimating blood pressure (BP) values from physiological signals (e.g., photoplethysmogram (PPG)) using deep learning models has recently received increased attention, yet challenges remain in terms of models' generalizability. Here, we propose taking a new approach by framing the problem as tracking the "changes" in BP over an interval, rather than directly estimating its value. Indeed, continuous monitoring of acute changes in BP holds promising implications for clinical applications (e.g., hypertensive emergencies). As a solution, we first present a self-contrastive masking (SCM) model, designed to perform pair-wise temporal comparisons within the input signal. We then leverage the proposed SCM model to introduce ΔBPNet, a model trained to detect elevations/drops greater than a given threshold in the systolic blood pressure (SBP) over an interval, from PPG. Using data from PulseDB, 1) we evaluate the performance of ΔBP-Net on previously unseen subjects, 2) we test ΔBP-Net's ability to generalize across domains by training and testing on different datasets, and 3) we compare the performance of ΔBP-Net with existing PPG-based BP-estimation models in detecting over-threshold SBP changes. Formulating the problem as a binary classification task (i.e., over-threshold SBP elevation/ drop or not), ΔBP-Net achieves 75.97%/73.19% accuracy on data from subjects unseen during training. Additionally, the proposed ΔBP-Net outperforms ΔSBP estimations derived from existing PPG-based BP-estimation methods. Overall, by shifting the focus from estimating the value of SBP to detecting overthreshold "changes" in SBP, this work introduces a new potential for using PPG in clinical BP monitoring, and takes a step forward in addressing the challenges related to the generalizability of PPG-based BP-estimation models.

Challenges Associated with the use of Smartwatches for out of Clinic Blood Pressure Monitoring Among Expectant Mothers in a Developing Country: A Case study of Nakuru County Kenya

Pre-eclampsia is a leading cause of maternal mortality globally and more so in developing countries. The condition, if detected early, can be prevented to avert death and suffering. This early detection has become easier with the development of devices such as smartwatches with BP sensors which have enhanced the practice of Ambulatory Blood Pressure Monitoring (ABPM) and Home Blood Pressure Monitoring (HBPM). However, most of these devices and monitoring practices have not been widely adopted in developing countries due to the high cost of devices and the lack of institutionalization of the ABPM and HBPM in healthcare systems. This study sought to examine the use of low-cost smartwatches, a mobile application, and a support system for the implementation of ABPM and HBPM among expectant mothers in Nakuru county, Kenya. A total of 34 expectant mothers were involved in the study over 8 months. A total of 967 readings were collected with only 3 out of the 34 mothers managing to take at least 71 readings during the period of the study. The study established that the use of low-specification phones that were incompatible with the mobile application, failure of the smartwatches to work appropriately, difficulties in getting mothers who met the inclusion criteria under 20 weeks gestation, poor adherence to the data collection, and loss of the devices negatively impacted the quality and consistency of BP monitoring among the expectant mothers. The study therefore recommends the use of more robust devices such as cuff BP readers and the inclusion of community health volunteers in the early identification of pregnant mothers from the community and subsequent follow-up for ABPM and HBPM.

Home versus Clinic Blood Pressure Monitoring: Evaluating Applicability in Hypertension Management via Telemedicine.

Hypertension is a significant public health concern in Saudi Arabia, affecting 28.6% of the population. Despite the availability of effective treatments, optimal blood pressure control is not always achieved, highlighting the need for effective management strategies. This study aimed to evaluate the applicability of home, compared to clinic, blood pressure measurements for managing hypertension in the Qassim region of Saudi Arabia. The study included 85 adults undergoing antihypertensive treatment. Home blood pressure measurements were obtained during the day and the evening using automated oscillometric sphygmomanometers, whereas clinic measurements were taken during clinic hours. Home blood pressure readings were significantly lower than clinic blood pressure readings, with mean differences of 20.4 mmHg and 4.1 mmHg for systolic and diastolic blood pressures, respectively. There was a positive correlation between the clinic systolic and diastolic blood pressures (r = 0.549, p < 0.001) and a weak correlation between the daytime home and clinic systolic blood pressures (r = 0.218, p < 0.05). This study provides insight into the applicability of home blood pressure monitoring, which may aid in the development of more effective hypertension management strategies, particularly the use of morning home blood pressure monitoring to aid treatment decisions through telehealth medicine.

Hypertension care during the COVID-19 pandemic in an integrated health care system.

Retention in hypertension care, medication adherence, and blood pressure (BP) may have been affected by the COVID-19 pandemic. In a retrospective cohort study of 64766 individuals with treated hypertension from an integrated health care system, we compared hypertension care during the year pre-COVID-19 (March 2019-February 2020) and the first year of COVID-19 (March 2020-February 2021). Retention in hypertension care was defined as receiving clinical BP measurements during COVID-19. Medication adherence was measured using prescription refills. Clinical care was assessed by in-person and virtual visits and changes in systolic and diastolic BP. The cohort had a mean age of 67.8 (12.2) years, 51.2% were women, and 73.5% were White. In 60757 individuals with BP measurements pre-COVID-19, 16618 (27.4%) had no BP measurements during COVID-19. Medication adherence declined from 86.0% to 80.8% (p< .001). In-person primary care visits decreased from 2.7 (2.7) to 1.4 (1.9) per year, while virtual contacts increased from 9.5 (12.2) to 11.2 (14.2) per year (both p < .001). Among individuals with BP measurements, mean (SD) systolic BP was 126.5 mm Hg (11.8) pre-COVID-19 and 127.3 mm Hg (12.6) during COVID-19 (p= .14). Mean diastolic BP was 73.5 mm Hg (8.5) pre-COVID-19 and 73.5 mm Hg (8.7) during COVID-19 (p= .77). Even in this integrated health care system, many individuals did not receive clinical BP monitoring during COVID-19. Most individuals who remained in care maintained pre-COVID BP. Targeted outreach may be necessary to restore care continuity and hypertension control at the population level.

Cost Effectiveness of Ambulatory Blood Pressure Monitoring Compared with Home or Clinic Blood Pressure Monitoring for Diagnosing Hypertension in Australia.

The aim of this study was to evaluate the cost effectiveness of ambulatory blood pressure monitoring (ABPM) compared with home blood pressure monitoring (HBPM) and clinic blood pressure monitoring (CBPM) in diagnosing hypertension in Australia. A cohort-based Markov model was built from the Payer's perspective (Australian government) comparing lifetime costs and effectiveness of ABPM, HBPM and CBPM in people aged ≥35 years with suspected hypertension who have a CBPM between ≥140/90mmHg and ≤180/110mmHg using a sphygmomanometer and have not yet commenced antihypertensive treatment. The main outcome measures were incremental cost-effectiveness ratio (ICER) assessing cost per quality-adjusted life-year (QALY) and life-years (LYs) gained by ABPM versus HBPM and CBPM. Cost was measured in Australian dollars (A$). Over a lifetime model, ABPM had lower total costs (A$8,491) compared with HBPM (A$9,648) and CBPM (A$10,206) per person. ABPM was associated with a small but significant improvement in the quality and quantity of life for people with suspected hypertension with 12.872 QALYs and 17.449 LYs compared with 12.857 QALYs and 17.433 LYs with HBPM, and 12.850 QALYs and 17.425 LYs with CBPM. In the base-case analysis, ABPM dominated HBPM and CBPM. In scenario analyses, at 100% specificity of HBPM, ABPM no longer remained cost effective at a A$50,000/QALY threshold. However, in probabilistic sensitivity analysis, over 10,000 iterations, ABPM remained dominant. ABPM was the dominant strategy for confirming the diagnosis of hypertension among Australian adults aged ≥35years old with suspected hypertension. The findings of this study are important for reimbursement decision makers to support policy change and for clinicians to make practice changes consistent with ABPM recommendations in primary care.

The association between long term blood pressure variability with incident dementia and cognitive impairment: A systematic review and meta‐analysis

AbstractBackgroundDementia cases continues to grow in the era of ageing population, with its number approaching 50 million. Accumulating evidence has shown that high blood pressure increases the risk of dementia and cognitive decline. In recent decades, some studies demonstrate that blood pressure variability (BPV) may contribute to cognitive decline and incident dementia independent of the blood pressure level. However, due to the inconsistence of statistical results and clinical methodology, the magnitude of this relationship remains ambiguous. A clear understanding of the role of BPV in dementia may shed light to etiology and early prevention of dementia. This study aims to assess the association between BPV with incident dementia and cognitive impairment.MethodWe searched MEDLINE, Embase, PsycINFO, CINAHL and Web of Science from December 2020 for articles describing trials, retrospective and prospective cohort studies in adults that assessed the association of long‐term BPV (measured through clinic blood pressure monitoring) with incident dementia and cognitive impairment. 5681 papers were identified and eventually 12 articles with full text and 3 abstracts with enough information were included in the quantitative analysis. Of these 15 studies, 2 articles report both dementia and cognitive decline or dysfunction as outcomes, while 5 studies report dementia as an outcome and 8 studies report cognitive decline or dysfunction.ResultHazard Ratio and linear regression coefficient were converted to a standardized one. We found that increased long‐term variability in systolic blood pressure was associated with higher risk of all‐cause dementia [pooled standardized HR of 1.1 (95%CI, 1.01, 1.19)]. Compared to people in lower BPV group, people in higher BPV group was 1.17 times more likely to develop dementia [pooled HR 1.17 (95%CI,1.12, 1.22)]. Cognitive decline was associated with higher SBPV [pooled linear coefficient for MMSE score is ‐0.11(95%CI, ‐0.17, ‐0.05)],which means MMSE score decreases by 0.11 per SD increase in SBPV.ConclusionOur findings suggested that higher long‐term blood pressure variability increases both the risk for incident dementia and cognitive decline.

Predicting prognosis in patients with stroke treated with intravenous alteplase through the 24-h trajectory of blood pressure changes.

Blood pressure (BP) monitored within 24 h from the beginning of intravenous thrombolysis (IVT) with alteplase, is one of the important factors affecting the prognosis of patients with acute ischemic stroke (AIS). This study aimed to explore longitudinal BP trajectory patterns and determine their association with stroke prognosis after thrombolysis. From November 2018 to September 2019, a total of 391 patients were enrolled consecutively during the study period, and 353 patients were ultimately analyzed. Five systolic (SBP) and four diastolic blood pressure (DBP) trajectory subgroups were identified. The regression analysis showed that when compared with the rapidly moderate stable group, the continuous fluctuation‐very high level SBP group (odds ratio [OR]: 2.743, 95% confidence interval [CI]: 1.008–7.467) was associated with early neurological deterioration (END). Both the rapid drop‐high level SBP (OR: 0.448, 95% CI: 0.219–0.919) and DBP groups (OR: 0.399, 95% CI: 0.219–0.727) were associated with early neurological improvement (ENI). Moreover, there was a U‐shaped correlation between the OR value of SBP trajectory group and favorable outcome (the modified Rankin Scale [mRS] score 0–2) at 3 months: the slow drop‐low level SBP group represent a well‐established unfavorable outcome risk factor (OR:5.239, 95% CI: 1.271–21.595), and extremely high SBP—the continuous fluctuation‐very high level SBP group, are equally associated with elevated unfavorable outcome risk (OR:3.797, 95% CI: 1.486–9.697). The continuous fluctuation‐very high level DBP group was statistically significant in mRS (OR: 3.387, CI: 1.185–9.683). The BP trajectory groups show varying clinical features and risk of neurological dysfunction. The findings may help identify potential candidates for clinical BP monitoring, control, and specialized care.

Prognostic Significance of ABPM in Comparison to Clinical Blood Pressure Monitoring and their Association with Various Risk Factors Involved in CKD Predisposition in North Indian Patients

Prognostic Significance of ABPM in Comparison to Clinical Blood Pressure Monitoring and their Association with Various Risk Factors Involved in CKD Predisposition in North Indian Patients

Clinical And Ambulatory Blood Pressure Monitoring In Subjects With Stent Implanted Aortic Coarctation

Abstract Background: This study aimed to investigate the frequency of systemic hypertension by clinical and ambulatory blood pressure monitoring in subjects with stent implanted aortic coarctation. Material and Methods: The study included in 31 subjects with stent implanted aortic coarctation before at least 6 months to 3 years. Related features of subjectes, procedure, echocardiografhic findings were evaluated retrospectively. Blood pressure were examined by classical method and 24-hour ambulatory blood pressure monitoring. Results: 22 of subjects were male and 9 were female. Mean age was 14,50 ±6,56 years. The mean body mass index was found to be 18,61 ±4,02.16 of them had native coarctation, others had recoarctation. The efficiency of procedure on blood pressure, echocardigraphic and angiocardiographic gradients was found to be statistically significant. 11 subjects were using antihypertensive drug. Six normotensive subjects had hypertensive in ambulatory blood pressure monitoring.17 subject were considered hypertensive group, others normotensive. There was not statistically significant difference between hypertensive group and normotensive group in demographic paramaters, coarctation type and diameter, the stent type and size, echocardiographic and catheter gradients before and after the procedure. Conclusions: Despite optimal treatment, hypertension persists in an important part of the subjects. Some normotensive subjects had hypertensive with ambulatory blood pressure monitoring. The study showed that clinical blood pressure monitoring does not sufficient to determined hypertension alone. Ambulatory blood pressure measurement with regular intervals will be beneficial in the follow-up of these subjects for hypertension.

Dipping pattern of nocturnal blood pressure in hypertensive patients treated with azilsartan

Aim: On average, blood pressure (BP) is found to be low during night than during day by approximately 10%–20%. In addition, BP decreases by >20% in some hypertensives or lowered by 140 mmHg; diastolic BP [DBP] >90 mmHg) were enrolled to performed ABPM and clinic BP monitoring with ongoing treatment with azilsartan. Statistical Analysis: Data are expressed as mean ± standard deviation. Statistical comparisons to test differences between two independent groups were by Student's t-test or Mann–Whitney's U-test as appropriate. Results: All patients monitored for 24-h BP measurement and reported to had SBP 133.76 ± 15.97 mmHg and DBP 76.16 ± 10.86 mmHg. Pulse rate was found to be 76.18 ± 11.82 bpm. BP variability was found to be high in 23.41% patients. Overall, study showed 34.17% dipper, 3.16% extreme dipper, 51.26% nondippers and 11.39% patients with reverse dipping pattern. In the present study, the dippers are classified to have 18.9% reduction in SBP, whereas 12.5% reduction in DBP. In the dippers group, only 4 patients had normal BP variation (2.53%), whereas high BP variation was found in 50 patients of the group (31.64%). Conclusions: ABPM had revealed higher SBP, BP variability (in almost one-fourth patients), dipping pattern and slightly higher pulse rates in hypertensive patients receiving azilsartan treatment. Around one-third of hypertensive patients were found to be dippers and more than half patients were non-dippers. Azilsartan has potent antihypertensive effect over 24 h and can be preferred in high-risk hypertensive patients.

CUFF-LESS BLOOD PRESSURE MONITORING DURING SLEEP

Objective:Home blood pressure monitoring as well as clinic blood pressure monitoring are recommended for the diagnosis or management of hypertension. Twenty-four-hour ambulatory blood pressure monitoring (ABPM) is helpful to detect abnormal circadian blood pressure patterns such as morning blood pre

The preliminary study of management model of morning hypertension in people with essential hypertension

Objective To analyze the epidemiological characteristics of morning hypertension in people with eseential hypertension in Dali Bai autonomous prefecture, and to study the management model for morning hypertension. Methods From May 2015 to January 2017, 302 patients with hypertension in the People's Hospital of Dali Bai Autonomous Prefecture were divided voluntarily into two groups, including single management group(group 1) and systematic management group (group 2). During six to twelve months follow-up, the changes in control rate of morning hypertension, serum biochemical indicators, KAP and Mofisky score were observed before and after intervention. Results The proportion of morning hypertension in people with hypertension was 62.25%, 61.11% in men and 62.86% in females.The patients with morning hypertension had higher age, BMI, WC, TC, LDL-C, SBP, DBP, CRP, FBG, SCr, Sokolow-Lyon, Cornell, LVMI, UACR and MAU, more cervical plaque, and lower HDL-C and eGFR compared with non-morning hypertension(P<0.05-0.001). The number of patients with target organ damage was most in patients with morning hypertension by home blood pressure monitoring(HBPM), second in ambulatory blood pressure monitoring(ABPM), least in clinic blood pressure monitoring(CBPM)(P<0.05-0.001). After six to twelve months follow-up, compared with before intervention, the control rate of morning hypertension was increased(43.78% vs.61.39%), and SBP, DBP, HR, BMI, WC, TC, TG, UA, Scr were decreased in both two groups, which in the group 2 were lower than those in the group 1(P<0.05). Compared with before intervention, the KAP score and Mofisky in the two groups after intervention were significantly improved(P<0.05-0.01)[K score: (9.63±3.01)points vs.(14.26±2.89)points in the group 1, (10.11±2.34)points vs.(17.23±1.06)points in the group2; A score: (2.05±1.21)points vs.(2.98±0.25)points in the group 1, (2.08±1.65)points vs.(3.56±0.42)points in the group 2, P score: (4.39±2.36)points vs.(5.89±3.24)points in the group 1, (4.71±3.42)points vs.(7.26±1.21)points in the group 2, Mofisky questionnaire score: (61.23±5.79)points vs.(72.36±6.18)points in the group 1, (60.89±6.47)points vs.(88.45±5.48)points in the group 2], which in the group 2 were higher than those in the group 1(P<0.01). Conclusion The control rate of morning hypertension in patients with hypertension in Dali Bai autonomous prefecture is low, the HBPM is better way to predict the target organ damage, and systematic management model is effective to improve the control rate of morning hypertension and so do in KAP and Morisky score. Key words: Hypertension; Morning hypertension; Management model; Home blood pressure monitoring

PROSPECTIVE EXTERNAL VALIDATION OF THE PREDICTING OUT-OF-OFFICE BLOOD PRESSURE (PROOF-BP) ALGORITHM

Objective: The PROOF-BP algorithm, which combines change in clinic blood pressure over multiple readings on a single occasion with patient characteristics, has been shown to predict a patient's out-of-office blood pressure (BP) level and hence determine whether subsequent ambulatory blood pressure monitoring (ABPM) is likely to affect decision making in the diagnosis of hypertension. The present study aimed to collect diagnostic data from routine practice to prospectively validate this new approach. Design and method: This study used a Prospective observational cohort design. Ten Primary Care practices and one hospital in the UK enrolled consecutive patients aged > 18 years, referred for ABPM. All participants underwent clinic BP monitoring, with the PROOF-BP algorithm applied, as well as daytime ABPM. Pre-specified outcomes included the proportion of true/false positive/negative results for detecting hypertension using the PROOF-BP strategy (algorithm + ABPM) compared to the reference ABPM. The sensitivity and specificity of the PROOF-ABPM strategy for detecting hypertension was compared to existing approaches including those recommended in the UK and US. Area under the receiver operator characteristic curve (AUROC) statistics were used to examine model performance. Results: A total of 887 patients (mean age 52.8 ± 16.2 years) were enrolled during the study period across all sites. PROOF-BP had a sensitivity of 97% which was better than existing approaches recommended in the UK (78%) and US (86%). However, PROOF-BP had a specificity of 76% which was worse than both UK (97%) and US (100%) approaches. AUROCs were highest in those strategies utilising ABPM. Overall, PROOF-BP resulted in more patients having their hypertensive status correctly classified (difference vs. UK 6%, p_0.001 Conclusions: Prospective validation of the PROOF-BP approach suggests it is possible to accurately classify an individual's hypertensive status with comparable or better accuracy and less utilisation of ABPM compared with existing strategies. The PROOF-BP strategy can be recommended for use in routine practice for patients where ambulatory blood pressure monitoring is being considered.

Ambulatory Blood Pressure Monitoring in Frequently Relapsing Nephrotic Syndrome.

To screen patients with frequently relapsing nephrotic syndrome (FRNS) for the presence of ambulatory hypertension and left ventricular hypertrophy. Following ethical and parental approvals, consecutive patients with FRNS of ≥2y duration were enrolled. Those with estimated glomerular filtration rate<60ml/min/1.73m2 and known familial hypercholesterolemia or diabetes mellitus were excluded. Clinic blood pressure was measured by oscillometryand 24-h ambulatory blood pressure was recorded by Spacelab 90207; echocardiography was done for left ventricular mass. Ambulatory hypertension wasdefined as the presence of clinic blood pressure>95th centile for age, sex and height, and systolic blood pressure load exceeding 25%. Of 99 patients, 73 were boys; their median (IQR) age was 120 (84-156)mo. Clinic blood pressure was >95th percentile in 63 (63.6%) patients. Ambulatory hypertension was present in 33 (33.3%), including 14 patients with severe hypertension; 16 (16.1%) had masked hypertension and 30 (30.3%) had white coat hypertension. Non-dipping was seen in 72 and 55 patients had high nocturnal systolic blood pressure load. Of 21 patients with increased left ventricular mass index, 9 (42.9%) had ambulatory hypertension, 3 (14.3%) had masked hypertension and 6 (28.6%) patients had white coat hypertension. Compared to those with normal blood pressure, patients with ambulatory hypertension were younger at onset of nephrotic syndrome (odds ratio, OR 0.94; 95% CI 0.91-0.98; P=0.002), longer duration of frequently relapsing disease (OR 1.05; 95% CI 1.00-1.10; P=0.034) and higher body mass index (BMI) (OR 1.61; 95% CI 1.07-4.40; P=0.020). BMI was positively correlated with 24-h systolic blood pressure load (r=0.23; P=0.002) and with the left ventricular mass index (r=0. 57; P=0.001). Many patients with FRNS showed high prevalence of clinic, ambulatory and white coat hypertension, emphasizing the need to carefully screen these patients in order to ensure their appropriate management. While clinic blood pressure monitoring detects most patients with hypertension, it misses a significant proportion with masked hypertension, underscoring the need for ambulatory blood pressure monitoring and screening for end organ damage. High BMI was the chief risk factor for hypertension, suggesting that control of overweight and hypertension might improve cardiovascular outcomes.

Cost-benefit analysis of home blood pressure monitoring in hypertension diagnosis and treatment: an insurer perspective.

Home blood pressure (BP) monitoring has been shown to be more effective than clinic BP monitoring for diagnosing and treating hypertension. However, reimbursement of home BP monitoring is uncommon in the United States because of a lack of evidence that it is cost beneficial for insurers. We develop a decision-analytic model, which we use to conduct a cost-benefit analysis from the perspective of the insurer. Model inputs are derived from the 2008 to 2011 claims data of a private health insurer in the United States, from 2009 to 2010 National Health and the Nutrition Examination Survey data, and from published meta-analyses. The model simulates the transitions among health states from initial physician visit to hypertension diagnosis, to treatment, to hypertension-related cardiovascular diseases, and patient death or resignation from the plan. We use the model to estimate cost-benefit ratios and both short- and long-run return on investment for home BP monitoring compared with clinic BP monitoring. Our results suggest that reimbursement of home BP monitoring is cost beneficial from an insurer's perspective for diagnosing and treating hypertension. Depending on the insurance plan and age group categories considered, estimated net savings associated with the use of home BP monitoring range from $33 to $166 per member in the first year and from $415 to $1364 in the long run (10 years). Return on investment ranges from $0.85 to $3.75 per dollar invested in the first year and from $7.50 to $19.34 per dollar invested in the long run.

High prevalence of masked uncontrolled hypertension in people with treated hypertension

There are limited data on the quality of treated blood pressure (BP) control during normal daily life, and in particular, the prevalence of 'masked uncontrolled hypertension' (MUCH) in people with treated and seemingly well-controlled BP is unknown. This is important because masked hypertension in 'treatment naïve' patients is associated with a high risk of cardiovascular events. We therefore conducted the first study to define the prevalence and characteristics of MUCH among a large sample of hypertensive patients in routine clinical practice in whom BP was treated and controlled to recommended clinic BP goals. We analysed data from the Spanish Society of Hypertension ambulatory blood pressure monitoring (ABPM) Registry and identified patients with treated and controlled BP according to current international guidelines (clinic BP <140/90 mmHg). Masked uncontrolled hypertension was diagnosed in these patients if despite controlled clinic BP, the mean 24-h ABPM average remained elevated (24-h systolic BP ≥130 mmHg and/or 24-h diastolic BP ≥80 mmHg). From 62 788 patients with treated BP in the Spanish registry, we identified 14 840 with treated and controlled clinic BP, of whom 4608 patients (31.1%) had MUCH according to 24-h ABPM criteria (mean age 59.4 years, 59.7% men). The prevalence of MUCH was significantly higher in males, patients with borderline clinic BP (130-9/80-9 mmHg), and patients at high cardiovascular risk (smokers, diabetes, obesity). Masked uncontrolled hypertension was most often because of poor control of nocturnal BP, with the proportion of patients in whom MUCH was solely attributable to an elevated nocturnal BP almost double that solely attributable to daytime BP elevation (24.3 vs. 12.9%, P < 0.001). The prevalence of masked suboptimal BP control in patients with treated and well-controlled clinic BP is high. Clinic BP monitoring alone is thus inadequate to optimize BP control because many patients have an elevated nocturnal BP. These findings suggest that ABPM should become more routine to confirm BP control, especially in higher risk groups and/or those with borderline control of clinic BP.

Identifying patients with hypertension using ABPM

The aim of this study was to assess the effectiveness of the systematic identification and sustained follow-up protocol of hypertensive patients using ambulatory blood pressure monitoring (ABPM) superimposed on Phase III cardiac rehabilitation (CR). Methods: Patients with elevated blood pressure (BP) (clinic measurement) on entry to CR had protocol cycles of ABPM, lifestyle education, medication changes and clinic BP monitoring, throughout CR and up to 6 months follow-up until BP control was achieved. Results: Initial assessment using clinic measurement identified 30% (129) patients with uncontrolled hypertension but following initial ABPM 62% (n=80) were normal with 38% (49) diagnosed as uncontrolled. These were followed-up using protocol cycles up to six times. Of those originally identified as hypertensive, 81% (104) achieved control. Conclusion: This systematic identification and sustained follow-up of hypertensive patients using ABPM in CR was a convenient, successful method in identifying and controlling a significant amount of uncontrolled hypertension.

Nocturnal Medications Dosing: Does It Really Make a Difference in Blood Pressure Control Among Patients with Chronic Kidney Disease?

Ambulatory blood pressure (BP) monitoring is superior to clinic BP monitoring in predicting long-term consequences of hypertension. This has raised interest in diurnal variation in BP and elevation in nighttime BP as a prognostic and therapeutic target. Several studies have identified prevalence of nocturnal hypertension in patients with accelerated progression of chronic kidney disease and target organ damage. Some studies suggest that nocturnal BP can be lowered by changing administration of antihypertensive medication to bed time; whether that results in retarding kidney disease progression is not very clear. Further research is needed to determine if certain classes of medications or interventions are superior in controlling nocturnal hypertension, and protocols need to be developed to screen patients for monitoring nocturnal BP. Further studies are needed to evaluate long-term renal outcomes of evening dosing in patients with nocturnal hypertension and chronic kidney disease.

Management of hypertension in adults in primary care: NICE guideline

Hypertension is common and is one of the leading causes of cardiovascular events such as stroke and ischaemic heart disease. It is responsible for approximately 12% of consultations in primary care. This is a summary of the key points in the 2011 National Institute for Health and Clinical Excellence (NICE) hypertension guideline.1 This is an update of NICE clinical guideline 18, which was first published in 2004 and was partially updated in 2006 (clinical guideline 34). The 2006 and 2011 updates were developed in collaboration with the British Hypertension Society (BHS). The areas included for updating were selected because of new evidence that might change existing recommendations. These included the use of ambulatory blood pressure monitoring (ABPM) and home blood pressure monitoring (HBPM) in diagnosis; the place of new thresholds and targets for treatment; and a re-examination of the position of angiotensin-converting inhibitors (ACEIs), angiotensin II receptor blockers (ARBs), calcium-channel blockers (CCBs), and diuretics in the treatment algorithm. Consideration of differences in management for people of various ages and ethnicity, as well as how to treat resistant hypertension, were also included. The management of blood pressure in people with diabetes was not included in this guideline. ### Diagnosis The diagnosis of hypertension uses both clinic blood pressure monitoring (CBPM) and ABPM readings (Box 1). If blood pressure measured in the clinic is 140/90 mmHg or higher, a second measurement should be taken during the consultation. If the second measurement is substantially different from the first, take a third measurement. The lower of the last two measurements should be recorded as …