Between Blood Pressure Measurements Research Articles

PP.10.19

Objective: Ambulatory blood pressure monitoring (ABPM) is being increasingly used in the assessment of hypertension in all age groups, confirming the continuous relationship between blood pressure (BP) and cardiovascular risk amongst older people. Moreover, ABPM seems to be is a more accurate predictor of cardiovascular morbidity and mortality than clinic measurements, providing a better estimate of BP load and identification of white-coat hypertension, a known common phenomenon in the elderly. The present analysis was undertaken to evaluate blood pressure profiles in subjects over 80 years old referred to our institution for ABPM in comparison with young subjects (18–30 years old). In view of the lack of data regarding ABPM in elderly people, we tried to better understand additional value of ABPM over office BP measuring and its reflections on patients’ treatment and follow-up. Design and method: 429 ABPMs of subjects aged 80 and over compared with 210 ABPMs of subjects between 18 and 30 years, referred at our Institution in the period 2000- 2014 were analyzed; all the recordings were performed using the same oscillometric device (TM 2430), in order to avoid confounding factors; all ABPMs fulfilled both the following criteria: > 23 hours recording and at least 2 valid measurements/hour (>70 % of total measures). Results: We identified hypertensive and normotensive subjects; hypertensives were furtherly subdivided in white coat, masked, isolated systolic, systo-diastolic and diastolic isolated hypertensives. Dipper and non dipper status (difference day- night > 10%) and post prandial fall were also calculated. Morning surge phenomenon and hypotension were also considered. Conclusions: Twenty-four-hour ABPM provides many measurements for better analysis and is likely to eliminate the stress of office visits and observer bias and proves to be a more accurate predictor of target organ damage and cardiovascular risk than routine office BP measurements. This tool seems to be of a certain importance even in the better evaluation of elderly subjects and in their possible therapeutic approach. White coat phenomenon seems to be a crucial parameter to be taken into account not only in younger subjects but also in elderly.

Lower blood pressure and apathy coincide in older persons with poorer functional ability: the Discontinuation of Antihypertensive Treatment in Elderly People (DANTE) Study Leiden.

To examine the association between blood pressure (BP) measures and symptoms of apathy and depression in older adults with various levels of functional ability. Cross-sectional study using baseline data from the Discontinuation of Antihypertensive Treatment in Elderly people (DANTE) Study Leiden. Primary care setting, the Netherlands. Community-dwelling individuals aged 75 and older (N = 430). Systolic BP (SBP), diastolic BP (DBP), and mean arterial pressure (MAP) were measured during home visits. Symptoms of apathy and depression were assessed using the Apathy Scale and the Geriatric Depression Scale (GDS-15), respectively. Stratified linear regression was performed in participants with better and worse functional ability according to the median of the Groningen Activity Restriction Scale. In participants with lower functional ability, each 10-mmHg lower SBP, DBP, and MAP was associated with higher Apathy Scale scores (0.63, 0.92, and 0.94 points, respectively, all P < .005) but not with GDS-15 scores. In participants with higher functional ability, BP measures were not associated with Apathy Scale or GDS-15 scores. In older participants with poorer functional ability, lower BP was associated with more symptoms of apathy but not depression.

Blood pressure as a risk factor for headache and migraine: a prospective population-based study.

During the past decade, several population-based studies have found an inverse association between blood pressure (BP) and headache. However, most of them have a cross-sectional design or lack a validated definition of a headache-free population at baseline. Therefore, additional population-based studies using a clearly defined headache-free population and a prospective design are warranted. Data from two large epidemiological studies, the Nord-Trondelag Health Survey 1995-1997 (HUNT 2) and 2006-2008 (HUNT 3), were used to evaluate the association between BP (systolic, diastolic and pulse pressure) at baseline and headache (migraine and tension type headache) at follow-up. An inverse relationship was found between all three BP measures at baseline in HUNT 2 and any headache in HUNT 3, more evident for systolic BP [odds ratio (OR) 0.90 per 10 mmHg increase in systolic BP, 95% confidence interval (CI) 0.87-0.93, P < 0.001] and pulse pressure (OR 0.84 per 10 mmHg increase in pulse pressure, 95% CI 0.80-0.89, P < 0.001) than for diastolic BP (OR 0.92 per 10 mmHg increase in diastolic BP, 95% CI 0.87-1.00, P = 0.036). The most robust finding, evident for both sexes, was that increased pulse pressure was linked to decreased prevalence of both migraine and tension type headache. An inverse relationship between BP and subsequent development of headache was confirmed in this large-scale population-based cohort study. Nevertheless, further research is needed to investigate the underlying mechanisms explaining these findings.

To wait or not to wait 1 min between office blood pressure readings.

It is recommended to wait at least 1 min between blood pressure (BP) readings. However, there is insufficient evidence on the utility of this recommendation using a validated automatic device. The aim was to assess differences in BP according to the waiting time between BP readings. The study was designed as a cross-sectional descriptive study in hypertensive patients attended in primary care.Patients were seated for 5 min before six baseline BP readings: three BP measurements with no waiting time [immediate readings (IR)] between them and three BP measurements with 1 min of waiting time [waiting readings (WR)] between each reading, in random order. The intraclass correlation coefficient was calculated between IR and WR mean BP measurements, with 95% confidence intervals (CIs). We included 150 hypertensive patients, 49.3% women, 65.6 (12.8) years of age. The mean systolic blood pressure (SBP) values for IR and WR measurements were 137.2 (95% CI 134.2-140.2) and 137.8 (95% CI 134.8-140.8) mmHg, respectively. The mean diastolic blood pressure (DBP) values for IR and WR measurements were 79.4 (95% CI 77.5-81.4) and 79.7 (95% CI 77.7-81.8) mmHg, respectively. Intraclass correlation coefficient between IR and WR was 0.959 (95% CI 0.943-0.970) and 0.926 (95% CI 0.898-0.946) for SBP and DBP, respectively. The mean difference between both methods for SBP and DBP was -0.60 (95% CI -1.79 to 0.5) and -0.27 (95% CI -1.33 to 0.77) mmHg, respectively. We found a good agreement between waiting or not waiting 1 min between office BP readings. This demonstrates that both methods of BP measurement appear to be interchangeable.

Troponin I and NT-proBNP and the Association of Systolic Blood Pressure With Outcomes in Incident Hemodialysis Patients: The Choices for Healthy Outcomes in Caring for ESRD (CHOICE) Study

There is uncertainty regarding treatment of hypertension in hemodialysis patients due to the observed J-shaped association between blood pressure (BP) and death. We hypothesized that this association reflects confounding by cardiovascular disease (CVD) and that stratification by CVD biomarkers, cardiac troponin I (cTnI) and N-terminal fragment of prohormone brain natriuretic peptide (NT-proBNP), might change this association. National prospective cohort study. 446 incident hemodialysis patients. Predialysis systolic BP. Mortality (all-cause and CVD) and first CVD event assessed using Cox regression adjusted for demographics, comorbid conditions, and clinical factors. Participants with cTnI level ≥0.1 ng/mL or NT-proBNP level ≥9,252 pg/mL were classified as the high-biomarker group; remaining participants were included in the low-biomarker group. Participants in the high-biomarker group (n=138 [31%]) were older (61 vs. 57 years) and had a higher prevalence of CVD (67% vs. 23%), but similar baseline BPs (152 vs. 153 mm Hg). There were 323 deaths (143 from CVD) and 271 CVD events. The high-biomarker group had a higher risk of mortality than the low-biomarker group (HR, 1.75; 95% CI, 1.37-2.24). The association between BP and outcomes differed between the 2 biomarker groups (P for interaction=0.01, 0.2, and 0.07 for all-cause mortality, CVD mortality, and first CVD event, respectively). In the low-biomarker group, BP was associated with greater risk of outcomes: HR per 10 mm Hg higher BP was 1.07 (95% CI, 1.01-1.14), 1.10 (95% CI, 0.96-1.25), and 1.04 (95% CI, 0.96-1.13) for all-cause mortality, CVD mortality, and first CVD event, respectively. Importantly, lower BP was not associated with increased risk of outcomes in stratified models, including for those in high biomarker group. BP measurements not standardized. The observed J-shaped association between BP and outcomes in hemodialysis patients is due to confounding by subclinical CVD. A stratification approach based on cTnI and NT-proBNP levels has the potential to inform BP treatment in hemodialysis patients.

Resting Energy Expenditure and Blood Pressure: Evidence of Perpetual Association

A myriad of cross-sectional and prospective studies have evaluated the interrelationship between blood pressure (BP) levels and different traditional metabolic surrogates including body mass index (BMI). In addition, clinically meaningful conditions such as hypertension and the metabolic syndrome independently of treatment for either condition have shown a prospective bidirectional association among different ethnicities and age burdens. However, along with the positive association between BP and adverse metabolic phenotypes, the exact underlying pathophysiological background has not yet been fully elucidated. Resting energy expenditure (REE), a quantitative measurement of metabolic processes at rest, was found to be correlated with BP levels in different ethnicities after adjustment for potential confounders. The arising clinical question is whether the measurement of REE might be a predictor of increasing BP levels or incident hypertension later in life independently of confounders including body adiposity and common pathophysiological pathways such as enhanced sympathetic nervous drive and subclinical inflammatory processes. To address the above clinical question, a longitudinal study has to be projected. However, it is also important to validate the reproducibility of the association over time, ie, sequential longitudinal evaluation of REE and BP levels. In the current issue of The Journal of Clinical Hypertension, Sriram and colleagues evaluated the association of systolic BP with REE in a cohort of 229 originally overweight premenopausal women without comorbidities who were recruited to participate in a weight loss program to normalize their BMI. After BMIrelated target achievement, the cohort of “newly normoweight” women was observed annually for 4 years and different adiposity surrogates were assessed in combination with BP and REE measurements during each individual investigational visit. The constant association of REE with BP at several follow-up timeframes after adjustment for confounders highlighted the consistency of the results over time. As a general comment, and beyond the purpose of the study by Sriram and colleagues, a successful weight loss intervention of limited time once again was not able to retain BMI within normal levels during the follow-up period. Indeed, the subset of women returned at the last visit had the same weight as before the intervention. However, we should point out that the rate of women who returned for follow-up visits was progressively reduced. Only 30 women returned for the last follow-up laboratory visit compared with 140 women with normalized BMI after weight loss intervention. Thus, prospective changes of body adiposity and REE in relation to BP changes could not be addressed by the design of the present study mainly as a result of reduced power for longitudinal evaluation. Curiously, only systolic BP was used as a principal outcome in the investigational approach of Sriram and colleagues. Although previous reports have demonstrated a mild relationship between REE and diastolic BP, the present study did not explain whether even this mild association persists overtime. Moreover, from a clinical point of view, diastolic BP might be more important compared with systolic BP in middle-aged patients. Additionally, bias regarding the exact methodology for measuring laboratory BP should not be neglected. It would be interesting to know the 24-hour profile of BP and measures of BP variability across visits. Although 24-hour BP measurements might be far different than laboratory resting BP, the former better reflects the overall hemodynamic load and may overcome eventual white-coat phenomena. A step further, does variability in laboratory BP correlate with REE variability across the 3 days of each individual followup laboratory visit? The answer to this question might enable us to better understand the reciprocal temporal changes of BP and REE. Although the procedure of REE assessment seems adequate because it is performed in laboratory conditions of “complete quiescence” after an overnight stay at a general clinical research center, neither the duration nor the quality of sleep the night before testing are reported. Under the hypothesis that participants did not demonstrate respiratory disorders during sleep, REE at awaking could be modulated by sleep characteristics. The role of the sympathetic nervous system in the pathophysiology of obesity-related hypertension is well established. We believe that a more sophisticated measurement of sympathetic nervous system activity, namely muscle nerve sympathetic activity, might better define its confounding effect compared with the measurement of urinary catecholamines alone. Over and under the above methodological remarks, the study by Sriram and colleagues set the basis for the prospective evaluation of REE either on BP levels or on Address for correspondence: Costas Thomopoulos, MD, 2, Helena Venizelou sqr, 11521 Athens, Greece E-mail: thokos@otenet.gr

Increase in blood pressure precedes clinical depression in elderly primary care patients

Previous studies on the relationship between blood pressure (BP) and depression have produced inconsistent results (Paterniti et al., 2000; Lenoir et al., 2008; Stewart and Hirani, 2010; Siennicki-Lantz et al., 2012). There have been no studies examining changes in BP prior to depression over a relatively long period. Participants in this study were primary care patients aged 60 years or older who screened negative for depression using the Center for Epidemiologic Studies Depression Scale (CES-D < 16) and had no prior depression diagnosis. Participants were screened from 1991 to 1993 during regularly scheduled primary care appointments at an urban public health system (Callahan et al., 1994). Participants were then followed through December 31, 2010. The study end point was defined as the time to a physician diagnosis of clinical depression based on International Classification of Disease codes. For patients not diagnosed with depression, date of the last encounter with the health system was their study endpoints. Clinical information was extracted from the Regenstrief Medical Record System including all height, weight, systolic BP, diastolic BP from outpatient visits, and 15 diagnoses (hypertension, diabetes, atherosclerotic vascular disease, coronary artery disease, peripheral artery disease, congestive heart failure, cerebrovascular disease, cancer, anemia, chronic obstructive pulmonary disease, arthritis, liver disease, renal disease, thyroid disease, hyperlipidemia, and dementia). Age, gender, race, years of education, and history of smoking were collected at enrollment. Repeated systolic and diastolic BP from enrollment to study endpoints were used as dependent variables in mixed effect models with random intercepts and random slopes while adjusting for time dependent covariates of patients’ medical conditions. The BP measures were aligned to each patient’s study endpoint, indexing a BP measure by the number of years this measure was taken before the patient’s endpoint. A total of 2581 participants were included with a median of 21 BP measures per patient. The mean times from enrollment to endpoints for the depression and no-depression groups were 7.2 years (SD = 4.6) and 7.9 years (SD = 5.8), respectively. Participants in the incident depression group had lower systolic BP at enrollment than those without depression (p = 0.0057) and were younger, more likely to be a woman, had a higher mean body mass index, and a higher rate of arthritis at enrollment (p < 0.0001). No other differences in rates of medical conditions were evident and the total numbers of comorbid conditions did not differ between the two groups at enrollment (p = 0.1699). A significant interaction between depression group and time was found for systolic BP indicating that systolic BP of those with incident depression increased significantly more than in those without depression (p < 0.0001) while adjusting for age, gender, race, body mass index, smoking, and medical conditions. Figure 1 illustrates the model by plotting predicted mean systolic BP over time for participants with incident depression and those without depression. An increasing trend is seen in systolic BP over time for the incident depression group, whereas the no-depression group showed a slight decrease in systolic BP toward the study endpoint. No significant main effects or interactions were found when diastolic BP was used as the dependent variable. Figure 1 Predicted mean systolic blood pressure over time for participants with incident depression and those without depression based on the final mixed effect model. In this depression-free cohort of older primary care patients followed for 18 years, we found that increases in systolic BP preceded the diagnosis of depression. The increase in systolic BP in participants with incident depression cannot be attributed to differences in medical conditions including cardiovascular diseases as these conditions were adjusted for in the models. The mechanism underlying the increase in systolic BP in participants with incident depression is not clear. Although increasing BP may act as an independent risk factor for late-life depression, it is also likely that both BP and depression were affected by other underlying factors such as stress, inflammation, or incipient vascular diseases. To our knowledge, this is the first study examining longitudinal trends in BP in elderly participants with incident late-life depression. The inclusion of longitudinal BP measures over a long period made it possible to examine BP trends in participants prior to depression diagnosis. Our study also has the advantage of excluding participants with baseline depression so that BP changes prior to new depression diagnosis can be examined. Our results suggest that increases in BP may be an important indicator for incipient late-life depression as well as for cardiovascular diseases in the elderly population.

Relationship between blood pressure and serum 25‐ hydroxyvitamin D among a young multi‐ethnic group living in South Florida

The aim of this cross‐sectional study was to investigate the relationship between blood pressure (BP) and serum 25‐ hydroxyvitamin D [25(OH)D] among a young multi‐ethnic group (N=81) living in South Florida. Participants included males (n=42) and females (n=39). A BP automated monitor with an adult size cuff was used to take two BP measures. Fasting serum 25(OH)D were determined by ELISA. Statistical analyses included t‐test and linear regression. The systolic blood pressure (SBP) was higher among males (115.1 ± 12.5) than females (101.9 ± 11.8) (P=&lt;0.001). One unit increase in serum 25(OH)D decreased diastolic blood pressure (DBP) by 0.350 units (P=0.018) when controlling for body mass index (BMI), age, education, race and years in the US. The results of this study suggested that there is an inverse relationship between serum 25(OH)D and DBP among males in this young multi‐ethnic group.

Systolic blood pressure and mortality in chronic hemodialysis patients: results of a nationwide italian study.

Studies on the relationship between blood pressure (BP) and mortality among hemodialysis patients have yielded conflicting results. Reports have come mostly from North America and have dealt with dialysis patients as a homogenous population and differed in methods and time of BP measurement and the optimal BP target. In a prospective nationwide study in 3674 unselected Caucasian patients with end-stage renal disease undergoing chronic hemodialysis from 73 dialysis units, the authors sought to examine the relationship between the different measurements of BP and mortality according to antihypertensive treatment. The mean age of patients was 67.2±14.1 years and the prevalence of diabetes was 19.5%. During follow-up (26.5±10.5months), 977 deaths were recorded. In the whole cohort, BP was not associated with mortality. After grouping the patients according to antihypertensive treatment, the analysis showed that only in patients who did not take antihypertensive medications (1613) was there an inverse relationship between postdialysis systolic BP and mortality. These patients differed from the others in BP, dialysis vintage, prevalence of diabetes, and type of dialysis technique. This study suggests that with respect to the relationship of BP with mortality, dialysis patients are not a homogenous population. Differences in demographic characteristics and in dialysis technique may therefore explain the reported variability of previous results.

Preliminary Blood Pressure Screening in a Representative Sample of Extremely Obese Kuwaiti Adolescents

A relationship between blood pressure (BP) and obesity has been found in young adults, but no data are available for adolescents in Kuwait. 257 adolescent (11–19 years) participants were categorized into two groups according to their BMI; 48 nonobese (21 males: 43.7% and 27 females: 56.3%) with mean age of 15.61 ± 2.40 years and 209 obese (128 males: 61.25% and 81 females: 38.75%) with mean age of 15.02 ± 2.82 years. The mean BMI was 21.7 ± 2.23 kg/m2 for the nonobese group and 34.47 ± 4.70 kg/m3 for the obese group. Most BP measures based on a single screening were significantly higher in the obese group. The prevalence of elevated BP was significantly higher in the obese subjects (nonobese: 13%; obese: 63%; P < 0.0001). In the obese group, there was a significant positive correlation between total sample BMI and all BP measures except the pulse pressure. There was a similar rate of elevated blood pressure between males and females (64% versus 60%; P = 0.66). For both isolated systolic elevated BP and isolated diastolic elevated BP, the prevalences were comparable between the males (systolic: 42%; diastolic: 5%) and females (systolic: 34%; diastolic: 14%). Only systolic BP was positively correlated with BMI in obese adolescent males (Spearman r = 0.18; P < 0.05), with a significant correlation between BMI with diastolic (Spearman r = 0.22; P < 0.05) and mean BP (Spearman r = 0.21; P < 0.05) in females.

Blood Pressure Variability in Elderly Persons With White-Coat and Masked Hypertension Compared to Those With Normotension and Sustained Hypertension

The relationship between blood pressure (BP) measured, its variability, and risk of cardiovascular events is well established; however, it is not well known whether there is a difference of variability between the four categories of BP status obtained by the comparison of office and home BP measurements: normotension and masked, white-coat, and sustained hypertension. Here, we assessed BP variability (BPV) according to BP status in the elderly. The study population consisted of 1,701 individuals aged ≥73 years drawn from the general population. Office and home BP measurements were obtained with the same device. At home, 18 measures were taken (3 in the morning, 3 in the evening, for 3 consecutive days). BP statuses were defined according to European Society of Hypertension recommendations. To assess BPV, seven indexes were defined (e.g., standard deviation of the 18 measures, day-to-day variability, triplet-to-triplet variability, and coefficient of variation). Subjects with white-coat hypertension and normotension had similar BPV, and the variability among those with masked hypertension was very close to that in those with sustained hypertension. Overall, BPV was much higher in subjects with masked hypertension than in those with white-coat hypertension, in both treated and untreated groups. In elderly individuals, the short-term variability of BP is similar in masked and sustained hypertension and higher than in normotension and white-coat hypertension. This result suggests the hypothesis that BPV among persons with masked hypertension may contribute to the elevated cardiovascular risk observed in this BP pattern.

Sleep-Time Blood Pressure: Prognostic Value and Relevance as a Therapeutic Target for Cardiovascular Risk Reduction

Correlation between blood pressure (BP) level and target organ damage, cardiovascular disease (CVD) risk, and long-term prognosis is greater for ambulatory BP monitoring (ABPM) than clinical BP measurements. Nevertheless, the latter continue to be the “gold standard” to diagnose hypertension, assess CVD risk, and evaluate hypertension treatment. Independent ABPM studies have found that elevated sleep-time BP is a better predictor of CVD risk than either the awake or 24-h BP mean. A major limitation of all previous ABPM-based prognostic studies is the reliance only upon a single baseline profile from each participant at the time of inclusion, without accounting for potential changes in the level and pattern of ambulatory BP thereafter during follow-up. Accordingly, impact of the alteration over time, i.e., during long-term follow-up, of specific features of the 24-h BP variation on CVD risk has never been properly investigated. We evaluated the comparative prognostic value of (i) clinic and ambulatory BP; (ii) different ABPM-derived characteristics, e.g., asleep or awake BP mean; and (iii) specific changes in ABPM characteristic during follow-up, mainly whether reduced CVD risk is more related to the progressive decrease of asleep or awake BP. We prospectively studied 3344 subjects (1718 men/1626 women), 52.6 ± 14.5 (mean ± SD) yrs of age, during a median follow-up of 5.6 yrs. Those with hypertension at baseline were randomized to ingest all their prescribed hypertension medications upon awakening or ≥1 of them at bedtime. At baseline, BP was measured at 20-min intervals from 07:00 to 23:00 h and at 30-min intervals at night for 48-h, and physical activity was simultaneously monitored every min by wrist actigraphy to accurately derive awake and asleep BP means. Identical assessment was scheduled annually and more frequently (quarterly) if treatment adjustment was required. Data collected either at baseline or the last ABPM evaluation per participant showed that the asleep systolic BP mean was the most significant predictor of both total CVD events and major CVD events (a composite of CVD death, myocardial infarction, and stroke). Moreover, when the asleep BP mean was adjusted by the awake mean, only the former was a significant independent predictor of outcome in a Cox proportional-hazard model adjusted for sex, age, diabetes, anemia, and chronic kidney disease. Analyses of changes in ambulatory BP during follow-up revealed 17% reduction in CVD risk for each 5 mm Hg decrease in the asleep systolic BP mean (p < .001), independent of changes in any other clinic or ambulatory BP parameter. The increased event-free survival associated with the progressive reduction in the asleep systolic BP mean during follow-up was significant for subjects with either normal or elevated BP at baseline. The ABPM-derived asleep BP mean was the most significant prognostic marker of CVD morbidity and mortality. Most important, the progressive decrease in asleep BP mean, a novel therapeutic target that requires proper patient evaluation by ABPM and best achieved by ingestion of at least one hypertension medication at bedtime, was the most significant predictor of event-free survival. (Author correspondence: rhermida@uvigo.es)

The Association Between Blood Pressure and Incident Alzheimer Disease

Many epidemiologic studies have considered the association between blood pressure (BP) and Alzheimer disease, yet the relationship remains poorly understood. In parallel with work on the AlzRisk online database (www.alzrisk.org), we conducted a systematic review to identify all epidemiologic studies meeting prespecified criteria reporting on the association between hypertension, systolic BP, or diastolic BP and incident Alzheimer disease. When possible, we computed summary measures using random-effects models and explored potential heterogeneity related to age at BP assessment. Eighteen studies reporting on 19 populations met the eligibility criteria. We computed summary relative risks (RR(Σ)) for 3 measures of BP: hypertension (RR(Σ) = 0.97 [95% confidence interval = 0.80-1.16]); a 10-mm Hg increase in systolic BP (RR(Σ) = 0.95 [0.91-1.00]); and a 10-mm Hg increase in diastolic BP (RR(Σ) = 0.94 [0.85-1.04]). We were unable to compute summary estimates for the association between categories of systolic or diastolic BP and Alzheimer disease; however, there did not appear to be a consistent pattern across studies. After stratifying on age at BP assessment, we found a suggestion of an inverse association between late-life hypertension and Alzheimer disease and a suggestion of an adverse association between midlife diastolic hypertension and Alzheimer disease. Based on existing epidemiologic research, we cannot determine whether there is a causal association between BP and Alzheimer disease. Selection bias and reverse causation may account for the suggested inverse association between late-life hypertension on Alzheimer disease, but, given the expected direction of these biases, they are less likely to account for the suggestion that midlife hypertension increases risk. We advocate continuing systematic review; the AlzRisk database entry on this topic (www.alzrisk.org), which was completed in parallel with this work, will be updated as new studies are published.

Comparative Assessment of Four Blood Pressure Measurement Methods in Hypertensives

Introduction Discordance between blood pressure (BP) measurement methods can occur and create ambiguity. New automated office BP monitors (AOBPs) are widely available, but their role is presently unclear. The objectives of this study are to quantify concordance among BP measurement methods and to define the diagnostic sensitivity, specificity, and predictive value of AOBPs in a population of hypertensive patients. Methods The office mercury sphygmomanometer, the AOBP, an ambulatory BP monitor (ABPM), and home self-measurement with an automatic device were compared in a randomized, crossover study. BP averages and achievement of therapeutic goals were defined. Comparisons and agreement tests were performed. Diagnostic indices were calculated for the AOBP. Results A total of 101 patients were enrolled. Average BP results were similar between measurement methods with the exception of daytime ABPM, which was significantly higher; figures are mean ± standard deviation (SD): sphygmomanometer, 129.9 ± 13.7/80.9 ± 9.3 mm Hg; AOBP, 128.4 ± 13.9/80.0 ± 9.4 mm Hg; 24-hour ABPM, 131.4 ± 11.7/78.7 ± 9.7 mm Hg; day ABPM, 135.5 ± 11.4/82.0 ± 11.9 mm Hg; home self-measurement, 131.0 ± 14.3/82.5 ± 8.2 mm Hg. Discordance in the achievement of therapeutic goals was observed in 58 patients, with only 26 cases being explained by masked hypertension or “white coat syndrome” according to all measurements. Disagreement was greater when office methods were compared with ambulatory methods. Conclusions This study shows that the 4 measurement strategies provide similar average BP estimates but generate many discordant results. The AOBP device can be very valuable as a replacement for the sphygmomanometer.

A spontaneous decrease of blood pressure occurs in acute ischemic stroke with favourable neurological course.

Background:In the acute phase of ischemic stroke the relationship between blood pressure (BP) and clinical outcome remains not clear. The aim of our study was to evaluate the association of stroke severity and BP measurements in the acute phase of stroke, and whether early variation of neurological status affects BP profiles. Methods:BP on admission was obtained with mercurial sphygmomanometer and 24h-ambulatory BP monitoring (ABPM) was performed on days 1st and 6th. Enrolled patient were grouped according to the neurological deficit at onset (graded by the NIHSS) in group A, (NIHSS score ≤ 10, mild/moderate) and group B (NIHSS score > 10, moderate/severe) and according to the occurrence of early neurological improvement, defined as a NIHSS score reduction of at least 4 points at the 6th day in group C (improved) and in group D (not improved).Results:A total of 57 patients were enrolled. On admission sphygmomanometric systolic BP values were higher in group A with respect to group B (158,5 mmHg ± 26,9 vs 147,7 mmHg ± 15,5 respectively; p = 0.6) whereas no difference was found in ABPM. On admission sphygmomanometric BP and ABPM were similar in group C and group D. At the 6th day ABPM, both systolic BP and diastolic BP values were significantly reduced in clinically improved patients (Δ systolic BP 1st to 6th day = 9,9±13,3 in group C vs 0,5±17,6 in group D, p < 0,05; Δ diastolic BP 1st to 6th day = 5,1± 8,4 mmHg in group C vs 1,3 ± 9,7 mmHg in group D, p = ns) whereas no change in the 24-h BP profile was observed in patients without early improvement.Conclusion:BP on admission in not related to the stroke severity and does not predict early neurological outcome and patients that show an early neurological improvement show also a reduction of the BP profile.

Cerebrovascular reactivity and dynamic autoregulation in ischaemic subcortical white matter disease

Background:It has been suggested that impaired cerebral autoregulation and vasodilatory capacity may play in role in the pathogenesis of the leukoaraiosis seen in small vessel disease. Adequate perfusion of the...

Characterizing blood pressure control in individuals with Type 2 diabetes: the relationship between clinic and self‐monitored blood pressure

To determine the relationship between blood pressure (BP) measurement in the clinic and self-monitored blood pressure (SMBP); and to evaluate the accuracy of self-reported data in patients with Type 2 diabetes treated intensively for hypertension. Seventy subjects had baseline and 1-week follow-up clinic BP measured using an Omron 907 automated device. During a contemporaneous 14-day period these subjects measured their BP at least four times each day using an Omron IC semiautomatic portable monitor which, unknown to them, contained an onboard memory capable of storing BP with corresponding time and date. There was no significant difference between mean clinic and mean self-monitored BP. Correlations between clinic BP and SMBP were r=0.61 (P<0.0001) for systolic BP and r=0.69 (P<0.0001) for diastolic BP. Clinic BP classified 56 subjects as uncontrolled hypertension (BP > or = 130/80 mmHg, adjusted for diabetes) and 14 subjects as controlled hypertension. Using World Health Organization-International Society of Hypertension criteria for SMBP (> or = 125/75 mmHg), 55 cases of clinic classified uncontrolled hypertension were confirmed, resulting in 98% sensitivity. Clinic and SMBP agreed in one case of controlled hypertension, resulting in 7% specificity. For all subjects, the median percent of values exceeding SMBP criteria for controlled hypertension was systolic 92% and diastolic 70%. Self-reporting precision averaged 89+/-10% (range 45-100%); under-reporting was 25+/-16% (ranging from 0 to 56%) and over-reporting was 12+/-15% (ranging from 0 to 46%). The overall logbook mean was not significantly different from the downloaded data from the Omron IC(R) monitors. SMBP was able to identify 13 patients with uncontrolled hypertension who, by clinic BP measurement, had been classified as controlled.

Ambulatory blood pressure and coronary artery calcification in middle-aged and younger adults

Background The objective of this study was to investigate relationships between blood pressure (BP) determined by ambulatory monitoring and coronary artery calcification (CAC) determined by electron beam computed tomography (EBCT) in middle-aged and younger adults without symptoms of coronary artery disease. Methods Measures of office and ambulatory BP were analyzed in 298 asymptomatic adults (134 women and 164 men) from the white population of Rochester, MN, who were 20 to 60 years old (mean ± SD, 40 ± 9 years). For the ambulatory BP measurements, the active period of the day was defined as the daytime, out-of-bed hours and the inactive period as the nighttime, in-bed hours. Logistic regression was used to assess whether ambulatory measures of BP influenced the probability of having CAC detected by EBCT. Results After adjusting for sex, age, and office measures of BP, ambulatory diastolic BP during the active and inactive periods were each statistically significant additional predictors of the probability of having CAC. Similarly, after adjusting for sex, age, and ambulatory systolic BP, ambulatory diastolic BPs during each period were also statistically significant additional predictors of the probability of having CAC. In contrast, measures of ambulatory systolic BP, pulse pressure, and diurnal dipping of BP levels from the active to the inactive period did not make statistically significant additional contributions to the probability of having CAC. Conclusion These findings emphasize the role that the hemodynamic stress of diastolic BP may play in the early development of atherosclerotic coronary artery disease.

¿Se puede o debe medir la presión arterial en las oficinas de farmacia?

To evaluate concordance between blood-pressure (BP) measurements at the pharmacy office (PhO) and the nurse office (NO) in the health care centre (HCC). Descriptive study. Community. 36 PhO have voluntarily participated in the province of Albacete, where they have done 3 BP measures, without previous instructions and with their usual measurements devices, for 3-5 subjects, who were referred to their HCC so that they were taken another 3 BP measures in the NO with their Hg sphymomanometer and in their usual measure conditions (blind measures in relation to those taken at the PhO). These subjects were given a stamped envelope to send the BP measurements (taken at the NO), to the Official Pharmacy College. The 6 BP measurements have been completed to 96 subjects with an average of 57.3 years old (women 63%). The differences between PhO and NO were > 5 mmHg in 58 subjects (60.4%) in the case of SBP and in 45 subjects (46.9%) in the case of DBP, and it was more than 15 mmHg in the 17 subjects (17.7%) with SBP and in 9 subjects (9.4%) with DBP. The difference average was 9.5 mmHg (SD, 8.4 mmHg) and 6.4 mmHg (SD, 5.3 mmHg) respectively. The use rate of digit 0 was 22% at the PhO and 46.5% at the NO. In most of PhO, measurement electronic devices have been used for the BP, but not validated for clinical use. The PhO can be a good place for the hypertension screening, but the chemist must be trained in the BP correct measurement and use validated electronic devices. Standardization measurement conditions and the use of validated electronic devices must be extended to the NO.

Importance of blood pressure control in hemodialysis patient survival

Importance of blood pressure control in hemodialysis patient survival.BackgroundIn the general population, hypertension is the leading cause of cardiovascular mortality. In dialysis patients, however, the relationship between blood pressure (BP) and mortality is controversial. We analyzed this relationship in hemodialysis (HD) patients.MethodsThe study population included 405 patients who had survived at least two years on HD. The observation period was initiated at the beginning of the third year. Predialysis BP measurements of all the dialysis treatments performed during the second year of HD was collected as the baseline data. Mean systolic BP (SBP) and mean diastolic BP (DBP) were calculated. Demographic and comorbidity data were collected at the start of the observation period (beginning of third year of HD). Mortality was analyzed at the end of the follow-up (death or December 31, 1998; total mortality), during the first two years of follow-up (years 3 and 4 of HD; early mortality) and after the second year of follow-up (≥5 years of HD; late mortality).ResultsIn the multivariate analysis, SBP and DBP were significantly associated with death. The adjusted total mortalities were U shaped. When early mortality was analyzed, only low BP (DBP <74.5 mm Hg) was significantly associated with mortality. When late mortality was analyzed, only high BP (SBP> 160 mm Hg) was significantly associated with mortality. In the early deaths, a cardiac cause was significantly less frequent, while withdrawal and malignancy were more frequent than in late deaths.ConclusionsThis study confirms that hypertension is a risk factor for mortality in HD patients, and shows the importance of the length of the follow-up time to demonstrate this relationship. The low frequency of a cardiac cause in the early death group suggests that the association between hypotension and mortality in HD patients is not related to cardiovascular causes, and only reflects the association between hypotension and other severe medical conditions. Importance of blood pressure control in hemodialysis patient survival. In the general population, hypertension is the leading cause of cardiovascular mortality. In dialysis patients, however, the relationship between blood pressure (BP) and mortality is controversial. We analyzed this relationship in hemodialysis (HD) patients. The study population included 405 patients who had survived at least two years on HD. The observation period was initiated at the beginning of the third year. Predialysis BP measurements of all the dialysis treatments performed during the second year of HD was collected as the baseline data. Mean systolic BP (SBP) and mean diastolic BP (DBP) were calculated. Demographic and comorbidity data were collected at the start of the observation period (beginning of third year of HD). Mortality was analyzed at the end of the follow-up (death or December 31, 1998; total mortality), during the first two years of follow-up (years 3 and 4 of HD; early mortality) and after the second year of follow-up (≥5 years of HD; late mortality). In the multivariate analysis, SBP and DBP were significantly associated with death. The adjusted total mortalities were U shaped. When early mortality was analyzed, only low BP (DBP <74.5 mm Hg) was significantly associated with mortality. When late mortality was analyzed, only high BP (SBP> 160 mm Hg) was significantly associated with mortality. In the early deaths, a cardiac cause was significantly less frequent, while withdrawal and malignancy were more frequent than in late deaths. This study confirms that hypertension is a risk factor for mortality in HD patients, and shows the importance of the length of the follow-up time to demonstrate this relationship. The low frequency of a cardiac cause in the early death group suggests that the association between hypotension and mortality in HD patients is not related to cardiovascular causes, and only reflects the association between hypotension and other severe medical conditions.