Office Blood Pressure Readings Research Articles

To Investigate the Prevalence of White Coat Hypertension in Community Dwelling Older Adults Referred for a Falls Assessment

Abstract Background Falls and frailty are the main focus in our integrated care programme for older persons (ICPOP). Office blood pressure (OBP) measurements are commonly used in practice although out of office recordings are proven to be a better predictor of cardiovascular risk (Myers et al, 2018). The European Society of Cardiology guidelines (ESC, 2018) have proposed BP values for the classification of hypertension (HTN). Methods We retrospectively completed a chart review on older adults’ who attended ICPOP with a referral for a falls assessment from November 2021 to April 2024. OBP were obtained after the patient was in the hub for approximately one hour following their comprehensive geriatric assessment (CGA). The OBP was documented following a supine period of 5 minutes. We compared the OBP and ambulatory blood pressure monitor (ABPm) average readings to assess the prevalence of HTN based on the ESC guidelines. Results 75 charts were reviewed. 3 ABPm recordings were unsuccessful due to cognitive impairment or not tolerating the ABPm. These were excluded from the audit. No patient had hypotension on either their OBP or ABPm recordings. On their OBP recordings, 29/72 (40%) had a normal reading while 43/72 (60%) had HTN. On their ABPm 54/72 (75%) had a normal reading while 18/72 (25%) had HTN. When we looked at antihypertensive medication use in those who had a normal reading on their ABPm, 47/54 (87%) were on antihypertensive treatment. All patients with HTN on their ABPM were on antihypertensive treatment. Conclusion Our findings suggest that OBP readings greatly increase the numbers of patients diagnosed with HTN compared to ABPm (60% versus 25%). Therefore, we suggest that all patients should have an ABPm as a gold standard to falls assessment to avoid over-treating white coat HTN.

Abstract P108: Correlations of attended and unattended office blood pressure measurements with Left Ventricular Mass in untreated hypertensives.

Introduction: Unattended (UA) office blood pressure (BP) measurements have been proposed as better substitutes for attended (AT) BP readings for the diagnosis and monitoring of patients with hypertension (HTN). A superior correlation of UA over AT BP measurements with Left Ventricular Hypertrophy (LVH), an early marker of hypertensive organ damage has not been conclusively demonstrated. We hypothesized that in a group with untreated HTN, UA BP would correlate more strongly with left ventricular hypertrophy than AT BP. Methods: Newly diagnosed untreated patients with HTN presenting newly to an outpatient clinic in Nigeria were consented as part of a larger study. Three sets of AT and UA seated BP readings were carried out using a validated device followed by same-day echocardiographic assessment of their Left Ventricular Mass Indexed to Body surface area (LVMI). Pearson’s coefficient (r) was determined and a 2-tailed significance was defined by a two-tailed P value (P) less than 0.05. Coefficients were compared using Fisher r to z transformation. Results: A total of 49 participants (female=25) were recruited with a mean age of 46.2 +/- 9 years. The mean of the AT BP in the cohort (mAT) was 157.1 +/- 13.5mmHg, while the mean of the UA BP was 151.9 +/- 15.7 with no significant difference in both (P=0.085). The mean LVMI of the cohort was 102.3 +/- 28.7 mg/m2. Both the mAT BP (r= 0.304, P= 0.034) and the mUA BP (r=0.354, P=0.013) positively correlated with LVMI, with no significant difference in the strength of both correlations with r to z transformation (z=0.27, P=0.394 ). Conclusion: In a small cohort of newly diagnosed Nigerian hypertensives, both attended and unattended systolic office blood pressure readings correlated positively with left ventricular mass indexed to body surface area, with no significant difference in the strength of their correlation. Having failed to demonstrate a superior correlation of unattended blood pressure readings with LVH, our findings support the continued use of attended office blood pressure readings for clinical monitoring in busy time-constrained office settings where unattended office blood pressure monitoring may not be feasible. Larger studies are however required to confirm these findings.

Abstract P321: Team-Based Care: A Winning Strategy for Managing Hypertension

Hypertension is a serious health condition that can lead to heart disease. Despite available methods for managing hypertension, blood pressure (BP) control in the US is declining, highlighting a gap between expert recommendations and real-world practice. Our clinic initiative aimed to create a specialized workflow and team, which included resident physicians, pharmacists, and health counselors focused on underserved communities. We also provided blood pressure cuffs and encouraged patients to monitor their blood pressure at home. This approach, coupled with the 'Knowing Your Numbers' campaign, has significantly improved outcomes, promoted continuity of care, and built resilience within care communities for vulnerable populations. 110 patients with poorly controlled hypertension were provided with BP monitors to track their blood pressure. Demographic data and office BP readings before and after the monitors were distributed were collected from patient charts. The results were analyzed using descriptive statistics and paired t-tests. The study included 58% female participants with an average age of 59. The racial distribution was 51% black, 35% white, 10% unreported/unknown, 2% Asian, and 2% American Indian/Alaska native. Most participants (70%) reported feeling empowered in their healthcare. Female participants who received a blood pressure cuff and engaged in shared decision-making experienced a significant reduction in their systolic BP by 17.6 mm Hg (P<0.05) and diastolic BP by 7.9 mm Hg (P<0.05). In comparison, males saw a reduction in their systolic BP by 10.6 mm Hg (P<0.05) and diastolic BP by 7.1 mm Hg (P<0.05). The average weight for both genders falls under the obese category, with females having an average BMI of 32.4 and males having an average BMI of 32.6. Providing loan-free blood pressure monitoring cuffs for clinic patients or blood pressure machines through insurance can improve patient engagement and health outcomes. Removing cost barriers can significantly impact in-office blood pressure reduction, monitoring, and patient satisfaction. This initiative highlights the importance of implementing patient-centered approaches to healthcare that address the financial and logistical barriers that can hinder effective hypertension management. Future research is needed to confirm these findings, but this study supports implementing similar programs to improve patients' health and well-being.

Abstract P324: Masked Hypertension Mimicking Migraine: A Case Report with Diagnostic Odyssey

Introduction: Masked hypertension (MH) involves normal office blood pressure but elevated readings outside clinical settings, increasing cardiovascular and neurological risks. About 10-30% of the population may have MH, often undiagnosed. This case highlights the importance of considering MH. Case Presentation: A 42-year-old woman had recurrent headaches for six months: bilateral, pulsating pain in the temples, with dizziness and occasional vomiting, lasting 2-4 hours, worsening after work. Diagnosed with migraines and treated with sumatriptan without relief. Medical history included a caesarean section; otherwise, she was healthy. Physical exam showed normal vital signs, including blood pressure at 130/80 mmHg. Neurological and ophthalmological evaluations were normal. Lab investigations were unremarkable. The patient had a normal BMI of 21.3. Further workup, including ECG, MRI, CT scan, and neck radiography, all normal. Ambulatory blood pressure monitoring (ABPM) revealed elevated blood pressure during evening hours (post work), starting around 4 pm and rising until 8-9 pm. Thereafter, blood pressure normalized to 110-130 mmHg systolic and 70-80 mmHg diastolic. To rule out nephrogenic hypertension, an ultrasound of the kidneys, renal function tests, urinalysis, and plasma metanephrine tests were negative. Following the exclusion of other causes, a diagnosis of MH was established. The patient started on Telmisartan 20 mg daily, with lifestyle modifications. Follow-up ABPM showed normalized blood pressure, and the patient reported no further headaches. Discussion: MH affects many but often remains undiagnosed due to normal clinic readings. Ambulatory or home blood pressure monitoring is essential for diagnosis. Timely diagnosis of MH is crucial, given its association with heightened risks of stroke and cardiovascular disease. Studies have revealed significantly elevated left ventricular mass index, maximal intima-media thickness, and urinary albumin levels. Consequences include left ventricular hypertrophy, carotid atherosclerosis, and albuminuria. Conclusion: Early recognition and management of MH are vital for preventing complications. Diagnosis can be achieved by home blood pressure monitoring (HBPM) or 24-hour ambulatory blood pressure. This case stresses considering MH in patients with normal office readings but persistent symptoms, advocating for regular monitoring and patient education for optimal health outcomes.

CORRELATION ANALYSIS BETWEEN VASCULAR OVERLOAD INDEX AND LEFT VENTRICULAR HYPERTROPHY IN HYPERTENSION

Objective: The vascular overload index (VOI) is commonly used to assess the’overload’phenomenon induced by hypertension,and vascular overload is one of the pathogenic mechanisms for left ventricular hypertrophy(LVH)associated with hypertension. The left ventricular mass index (LVMI) is the most frequently used diagnostic indicator for LVH. Research has found that VOI derived from office blood pressure readings is correlated with LVH,but it doesn’t evaluate the relationship between vascular load during different periods of the day and LVH. This study aims to investigate the correlation between VOI obtained from 24-hour ambulatory blood pressure and LVH. Design and method: A total of 591 hypertensive patients hospitalized from July 2020 to July 2022 were included. Echocardiography was performed in each patient,and the LVMI was calculated; The 24-hour VOI(VOI24h=1.33×SBP24h-0.33×DBP24h-133.3mmHg),daytime VOI(VOId),and nighttime VOI(VOIn)were calculated based on the 24-hour ambulatory blood pressure results. A multivariate logistic regression was utilized to explore the correlation between VOI at different times and LVH,adjusting for covariates such as gender,age,BMI,triglycerides,cholesterol,HDLand LDL. Results: The age of the 591 hypertensive patients was 63.8±13.3years and BMI was 25.7±3.6Kg/m2.Univariate linear regression analysis showed that VOI24h,VOId,and VOIn were positively correlated with LVMI(P<0.001). After adjusting,all of VOI remained correlated with LVMI. Compared with the lowest tertile of VOI24h, the highest tertile had β (95%CI) of 9.25(6.09∼12.4). For VOId,the highest tertile compared to the lowest had β (95%CI) of 8.70(5.55∼11.86),and for VOIn,it was 9.48(6.32∼12.64).Univariate logistic regression analysis indicated that all of VOI were significantly associated with LVH(P<0.001),and after adjusting for confounders,all of VOI still correlated with LVH,with OR(95%CI)respectively being 1.04(1.02∼1.07),1.04(1.02∼1.07),and 1.03(1.01∼1.05). Subgroup analysis revealed that regardless of the comorbidity of the hypertensive patients,all of VOI were all related to LVH.However, when analyzed by season,VOI24h and VOId were significantly associated with LVH in summer and winter, but not in spring and autumn; VOIn was only associated with LVH in winter. Conclusions: In the hypertensive patients,VOI derived from 24-hour ambulatory blood pressure is significantly correlated with LVH. Compared to spring and autumn,vascular load during summer and winter is significantly associated with LVH. Therefore,not only should steady blood pressure control over 24 hours be emphasized,but also pay attention to the impact of vascular load on LVH during summer and winter.

Awareness of Hypertension in Reproductive-Aged Women Living With Chronic Kidney Disease

BackgroundHypertension is the most important modifiable cardiovascular risk factor among women. Chronic kidney disease (CKD), which affects 1 in 10 reproductive-aged women, increases the risk of hypertension; however, awareness of hypertension in this population is unknown. This study aimed to determine hypertension awareness among reproductive-aged women living with chronic kidney disease. MethodsWomen aged 18 to 50 years with CKD were recruited from nephrology clinics in Calgary, Alberta, Canada. Participants completed a semistructured interview and focused chart review, serum and urine laboratory assessment, and a physical examination that included anthropomorphic measurements and 2 automated office blood pressure readings. Hypertension was defined according to the use of ≥ 1 antihypertensive medications and/or an automated office blood pressure reading of ≥ 135/85 mm Hg. Data were stratified by hypertension status, as well as by awareness, and descriptively presented as mean ± standard deviation, numerical values, and percentages. ResultsSixty-three participants with CKD were included. Thirty-eight (60%) participants had hypertension according to study definitions. Of those with hypertension, 30 participants (79%) were aware of their hypertension status. ConclusionsHypertension awareness is relatively high in reproductive-aged women living with CKD. However, hypertension awareness is the critical component for hypertension management, and further work is necessary to optimize reduction of cardiovascular risk in this important population.

Arterial stiffness assessment in patients with resistant hypertension using pulse wave analysis

Abstract Introduction People living with resistant hypertension (RH) have a higher prevalence of target organ damage, and demonstrate increased risk of cardiovascular (CV) morbidity and mortality. There are distinctive vascular structural and functional changes associated with hypertension. Among these, endothelial dysfunction and increased arterial stiffness are prevalent. Increased aortic augmentation index (AIx) is a non-invasive hemodynamic indicator of systemic arterial stiffness, which has been associated with hypertension; however, there are less data in RH patients. Purpose To test the hypothesis that people living with RH have increased AIx compared to those with controlled essential hypertension (CH) and normotensive controls (NC); and to explore demographic and clinical variables related to AIx. Methods In our observational study, 54 participants: 17 with RH (mean age 60.5±12.4 years), 18 with CH (57.7±12.2 years), and 19 NC (54.7±11.9 years) were recruited. Anthropometric and resting office blood pressure (BP) measurements were obtained. Pulse wave analysis was performed using a commercially available device (Vicorder) to measure central BP, aortic pulse pressure, mean arterial pressure (MAP), aortic augmentation pressure and AIx. Results The study groups were matched for age, sex, ethnicity, height, body surface area and heart rate (P>0.05) (Table 1). Both office and central BP readings were elevated in RH group compared to CH and NC (162/102mmHg vs 126/86mmHg and 118/80mmHg, P<0.001) and (163/83mmHg vs 131/73mmHg and 120/67mmHg, P<0.05). Aortic pulse pressure, MAP and aortic augmentation pressure were significantly increased in patients with RH compared to other groups (P<0.001). AIx was markedly increased in RH compared to CH and NC (31±7% vs 23±8% and 21±9%, P=0.001, respectively). Antihypertensive medications were similar between both hypertensive groups, except for diuretics and beta-blockers which were more prevalent in the RH group (100% vs 28% and 47% vs 6%, P<0.05, respectively). In stepwise regression analysis, elevated AIx was significantly and independently associated with the presence of RH (β=6.4, P=0.005), age (β=.23, P=0.005), female sex (β=6.3, P=0.003) and body mass index (β=.71, P=0.038). Conclusion AIx is increased in RH patients and independently related to the presence of RH, age, female sex and body mass index. Increased arterial stiffness and reduced arterial compliance in patients with RH may play an important role in the progression of serious CV complications seen in these patients. The non-invasive assessment of arterial stiffness indices such as AIx in RH patients may be valuable to provide prognostic and therapeutic insights.Table 1

Impact of Successive Office Blood Pressure Measurements During a Single Visit on Cardiovascular Risk Prediction: Analysis of CARTaGENE.

Multiple office blood pressure (BP) readings correlate more closely with ambulatory BP than single readings. Whether they are associated with long-term outcomes and improve cardiovascular risk prediction is unknown. Our objective was to assess the long-term impact of multiple office BP readings. We used data from CARTaGENE, a population-based survey comprising individuals aged 40 to 70 years. Three BP readings (BP1, BP2, and BP3) at 2-minute intervals were obtained using a semiautomated device. They were averaged to generate BP1-2, BP2-3, and BP1-2-3 for systolic BP (SBP) and diastolic BP. Cardiovascular events (major adverse cardiovascular event [MACE]: cardiovascular death, stroke, and myocardial infarction) during a 10-year follow-up were recorded. Associations with MACE were obtained using adjusted Cox models. Predictive performance was assessed with 10-year atherosclerotic cardiovascular disease scores and their associated C statistics. In the 17 966 eligible individuals, 2378 experienced a MACE during follow-up. Crude SBP values ranged from 122.5 to 126.5 mm Hg. SBP3 had the strongest association with MACE incidence (hazard ratio, 1.10 [1.05-1.15] per SD) and SBP1 the weakest (hazard ratio, 1.06 [1.01-1.10]). All models including SBP1 (SBP1, SBP1-2, and SBP1-2-3) were underperformed. At a given SBP value, the excess MACE risk conferred by SBP3 was 2× greater than SBP1. In atherosclerotic cardiovascular disease scores, SBP3 yielded the highest C statistic, significantly higher than most other SBP measures. In contrast to SBP, all diastolic BP readings yielded similar results. Cardiovascular risk prediction is improved by successive office SBP values, especially when the first reading is discarded. These findings reinforce the necessity of using multiple office BP readings.

SAFETY, FEASIBILITY, AND ACCEPTABILITY OF TELEMEDICINE FOR HYPERTENSION IN PRIMARY CARE: A PROOF-OF-CONCEPT AND PILOT RANDOMIZED CONTROLLED TRIAL (SATE-HT)

Objective: Hypertension (HT) continues to be a leading cause of cardiovascular death and an enormous burden on the healthcare system. Although telemedicine may provide improved blood pressure (BP) monitoring and control, it remains unclear whether it could replace face-to-face consultations in patients with optimal BP control. We hypothesized that an automatic drug refill coupled with a telemedicine system tailored to patients with optimal BP would lead to non-inferior BP control Design and method: In this pilot, multicenter, randomized control trial (RCT), participants receiving anti-HT medications were randomly assigned (1:1) to either the telemedicine or usual care group. Patients in the telemedicine group measured and transmitted their home BP readings to the clinic. The medications were refilled without consultation when optimal control (BP <135/85 mmHg) was confirmed. The primary outcome of this trial was the feasibility of using the telemedicine app. Office and ambulatory BP readings were compared between the two groups at the study endpoint. Acceptability was assessed through interviews with the telemedicine study participants. Results: Overall, 49 participants were recruited in 6 months and retention rate was 98%. Participants from both groups had similar BP control (daytime systolic BP: 128.2 versus 126.9 mmHg [telemedicine vs. usual care], p = 0.41) and no adverse events. Participants in the telemedicine group had fewer general outpatient clinic attendances (0.8 vs. 2, p<0.001). Interviewees reported that the system was convenient, timesaving, cost saving, and educational. Conclusions: The system could be safely used. However, the results must be verified in an adequately powered RCT.

Improving Access to Home Blood Pressure Monitors at a Federally Qualified Health Center.

Background: Self-monitoring of blood pressure (BP) clinically decreases BP. However, cost can limit access, especially in underserved populations. Objective: This mixed-methods pilot study aims to determine the impact of providing home BP monitors free of charge to patients at a federally qualified health center (FQHC) by quantifying the effect on BP and surveying patients to measure satisfaction and engagement. Methods: One hundred eighty patients with clinically diagnosed hypertension received BP monitors. Patient charts were reviewed to collect demographics and office BP readings 3 months before and after receiving a monitor. A 13-question phone survey was conducted to a sample of patients addressing satisfaction and engagement. Answers were based on a Likert scale and dichotomous yes/no. Results were analyzed with descriptive statistics and paired t tests. Results: The chart review demonstrated a significant mean decrease in systolic BP by 5.44 mm Hg (P < 0.001, -8.03 to -2.84) and a mean decrease in diastolic BP by 2.70 mm Hg (P < 0.001, -4.08 to -1.32) after the intervention. For those included who responded to the survey (13%), there was a significant mean increase in the frequency of checking BP per week by 1.5 Likert points (P < 0.00001, -1.0 to -1.9), and a majority (57.8%) felt slightly or much more active in their health care in addition to other benefits. Conclusion: Providing BP monitors to FQHC patients free of charge may have contributed to a significantly decreased office BP, improved engagement, and satisfaction. This program removed cost barriers and allowed patients to be more active in their health care.

Safety, Feasibility, and Acceptability of Telemedicine for Hypertension in Primary Care: A Proof-of-concept and Pilot Randomized Controlled Trial (SATE-HT).

Hypertension (HT) continues to be a leading cause of cardiovascular death and an enormous burden on the healthcare system. Although telemedicine may provide improved blood pressure (BP) monitoring and control, it remains unclear whether it could replace face-to-face consultations in patients with optimal BP control. We hypothesized that an automatic drug refill coupled with a telemedicine system tailored to patients with optimal BP would lead to non-inferior BP control. In this pilot, multicenter, randomized control trial (RCT), participants receiving anti-HT medications were randomly assigned (1:1) to either the telemedicine or usual care group. Patients in the telemedicine group measured and transmitted their home BP readings to the clinic. The medications were refilled without consultation when optimal control (BP < 135/85 mmHg) was confirmed. The primary outcome of this trial was the feasibility of using the telemedicine app. Office and ambulatory BP readings were compared between the two groups at the study endpoint. Acceptability was assessed through interviews with the telemedicine study participants. Overall, 49 participants were recruited in 6 months and retention rate was 98%. Participants from both groups had similar BP control (daytime systolic BP: 128.2 versus 126.9 mmHg [telemedicine vs. usual care], p = 0.41) and no adverse events. Participants in the telemedicine group had fewer general outpatient clinic attendances (0.8 vs. 2, p < 0.001). Interviewees reported that the system was convenient, timesaving, cost saving, and educational. The system could be safely used. However, the results must be verified in an adequately powered RCT. Trial registration: NCT04542564.

Is a unified blood pressure threshold feasible in the current scenario?: Commentary on the article"130/80mmHg as a unifying hypertension threshold for office brachial, office central and ambulatory daytime brachial blood pressure": Commentary on the article"130/80mmHg as a unifying hypertension threshold for office brachial, office central and ambulatory daytime brachial blood pressure".

Is a unified blood pressure threshold feasible in the current scenario?: Commentary on the article"130/80mmHg as a unifying hypertension threshold for office brachial, office central and ambulatory daytime brachial blood pressure": Commentary on the article"130/80mmHg as a unifying hypertension threshold for office brachial, office central and ambulatory daytime brachial blood pressure".

Utility of ambulatory blood pressure monitoring in detection of masked hypertension and risk of hypertension mediated organ damage in normotensive patients with type 2 diabetes mellitus

Purpose In patients with diabetes, unrecognised hypertension is a serious problem risk factor for the development and progression of chronic complications. The study aimed to determine the prevalence of masked hypertension in normotensive diabetic patients, the factors affecting it, and its association with diabetes complications using ambulatory blood pressure monitoring (ABPM). Materials and methods A cross-sectional observational study was conducted on 150 normotensive diabetic patients. Patients were subjected to an interview and clinical examination to record demographic data, epidemiological data, and significant past history. ABPM was performed for each patient. Urine samples, echocardiogram, and ophthalmologic fundoscopy were done to check for diabetes-related complications. Results The mean age of all participants was 56.7 ± 7.8 years. A total of 93 patients (62%) were males. 99 (66%) patients had masked hypertension. A total of 85 (56.7%) were non-dippers, 49 (32.7%) were dippers, 1 (0.7%) was extreme dipper and 15 (10%) were reverse dippers. Non-dipping and reverse dipping were associated with concentric left ventricular hypertrophy LVH (p < .001). Masked hypertension was associated with concentric LVH (p = .001) and nephropathy (p =.008) whereas, nocturnal hypertension was associated with concentric LVH (p = .001) and nephropathy (p =.003). Conclusions A single office blood pressure (BP) reading cannot rule out hypertension in patients with diabetes. Regardless of hypertension, clinicians should have all patients, especially patients with diabetes, undergo ABPM at least once. Masked hypertension, changes in nocturnal dipping and other phenomena that raise the risk of diabetes complications but cannot be measured by office BP can be measured by ABPM, and thus ABPM can provide a good prognostic benefit.

Predicting Out-of-Office Blood Pressure in a Diverse US Population.

BACKGROUNDThe PRedicting Out-of-OFfice Blood Pressure (PROOF-BP) algorithm accurately predicted out-of-office blood pressure (BP) among adults with suspected high BP in the United Kingdom and Canada. We tested the accuracy of PROOF-BP in a diverse US population and evaluated a newly developed US-specific algorithm (PROOF-BP-US).METHODSAdults with ≥2 office BP readings and ≥10 awake BP readings on 24-hour ambulatory BP monitoring from 4 pooled US studies were included. We compared mean awake BP with predicted out-of-office BP using PROOF-BP and PROOF-BP-US. Our primary outcomes were hypertensive out-of-office systolic BP (SBP) ≥130 mm Hg and diastolic BP (DBP) ≥80 mm Hg.RESULTSWe included 3,058 adults, mean (SD) age was 52.0 (11.9) years, 38% were male, and 54% were Black. The area under the receiver-operator characteristic (AUROC) curve (95% confidence interval) for hypertensive out-of-office SBP was 0.81 (0.79–0.82) and DBP was 0.76 (0.74–0.78) for PROOF-BP. For PROOF-BP-US, the AUROC curve for hypertensive out-of-office SBP was 0.82 (0.81–0.83) and for DBP was 0.81 (0.79–0.83). The optimal predicted out-of-office BP ranges for out-of-office BP measurement referral were 120–134/75–84 mm Hg for PROOF-BP and 125–134/75–84 mm Hg for PROOF-BP-US. The 2017 American College of Cardiology/American Heart Association BP guideline (referral range 130–159/80–99 mm Hg) would refer 93.1% of adults not taking antihypertensive medications with office BP ≥130/80 mm Hg in the National Health and Nutrition Examination Survey for out-of-office BP measurement, compared with 53.1% using PROOF-BP and 46.8% using PROOF-BP-US.CONCLUSIONSPROOF-BP and PROOF-BP-US accurately predicted out-of-office hypertension in a diverse sample of US adults.

The Utility of 24-h Ambulatory Blood Pressure Monitoring for the Diagnosis and Management of White Coat Hypertension in a Primary Care Setting

Objectives:Twenty-four-hour ambulatory blood pressure monitoring (ABPM) is recommended in patients with white coat hypertension (HTN) by national guideline, but was poorly utilized, and is available only in very limited subspecialty clinics. We aim to examine the feasibility and utility of ABPM in a primary care setting in the diagnosis and management of white coat HTN including the implementation and modification of antihypertensive therapy.Methods:Patients who have elevated blood pressure in clinic office but normal blood pressure readings at home are eligible for 24-h ambulatory BP monitoring. We analyzed data from patients who were suspected to have white coat HTN in the last 2 years underwent ABPM in our practice.Results:Among 68 patients, 54 patients met the selection criteria. ABPM showed that 13 patients had normal BP (24%), while 41 patients (76%) had persistent HTN. Among these patients with persistent HTN, 28 patients had intervention including 24 patients prescribed with new anti-hypertensive medication or medication increase, 3 patients prescribed with additional lifestyle modification and one started CPAP.13 patients with slightly elevated BP (133/77 for average daytime BP) didn’t have medication adjustment.Conclusion:ABPM has substantial utility in the diagnosis and management of white coat HTN in a primary care setting.

Ambulatory blood pressure monitoring and its utility in management of hypertension in a clinic setting in South India

Introduction: High blood pressure (BP) is an important risk factor for cardiovascular diseases. The association of short-term BP variability (BPV) with target organ damage (TOD) is not clearly established. We conducted this observational study to evaluate the degree of concordance between Office BP measurements (OBPM) and ambulatory BP monitoring (ABPM) and to study the association of ABPM parameters on TOD. Materials and Methods: Patients attending clinics of the authors between January 2018 and August 2019 were enrolled. Their BP status was determined by OBPM and ABPM and the degree of concordance analyzed. ABPM parameters between those with TOD and without TOD were compared using appropriate statistical measures. Results: Data from 968 subjects (males 61.5%, mean age 59.39 ± 14.86 years) were analyzed. Masked hypertension (HTN) and white coat HTN were seen in 138 (14.3%) and 50 (5.2%) participants, respectively. There was moderate concordance between ABPM and OBPM readings (Cohen's κ =0.571, 95% confidence interval [CI]: 0.445, 0.595, P < 0.001). There were 530 (54.8%) nondippers and 189 (19.5%) reverse dippers. High morning surge (MS) was seen in 193 patients (19.9%) and TOD was seen in 378 patients (39%). Among all the ABPM parameters which were significantly associated with TOD on univariate analysis, only BPV (P = 0.04, odds ratio [OR]: 1.04, 95% CI: 1.00, 1.08) and systolic BP in active phase (P = 0.01, OR: 1.02, 95% CI: 1.00, 1.04) were found to be predictors of TOD after multiple logistic regression analysis. Dipping status and MS were not associated with TOD. Conclusions: ABPM is a useful tool for diagnosis and accurate categorization of HTN. The analysis of ABPM parameters helps to identify the patients with BPV which has important implications for the prevention of TOD. ABPM is recommended in all individuals with cardiometabolic risk profile or with established TOD even with normal office BP readings.

Comparative accuracies of automated and manual office blood pressure measurements in a Chinese population.

We aimed to assess the difference in the accuracy of readings from automated office blood pressure machines with each other or with manual office blood pressure measurements in Chinese individuals. We collected awake 48-h ambulatory blood pressure monitoring, two automated office blood pressure device (BpTRU and WatchBP) readings, and manual office blood pressure measurements in Chinese patients (n = 135) with hypertension in a randomized sequence. Differences were compared using paired t-tests and Bland-Altman plots. The sensitivity and specificity of the techniques for detecting elevated blood pressure were calculated using awake ambulatory blood pressure monitoring as the reference standard. The WatchBP device's and awake ambulatory blood pressure readings were similar. The BpTRU device provided significantly lower mean systolic (P < 0.001) and diastolic (P < 0.001) blood pressure readings, while manual office BP provided significantly higher mean systolic (P = 0.008) and diastolic (P < 0.001) blood pressure readings than the awake automated office blood pressure readings. Automated and manual office blood pressure measurements showed similar sensitivity, specificity, and 95% limits of agreement as based on Bland-Altman plots. The mean systolic (P < 0.001) and diastolic (P < 0.02) blood pressure readings of WatchBP and BpTRU differed, and their diagnostic performances were not superior than those of manual office blood pressure measurements in Chinese patients. Therefore, automated office blood pressure measurements cannot be routinely recommended for Chinese individuals in clinical practice. More studies are needed to confirm these results.

Blood pressure measurement: Should technique define targets?

Accurate assessment of blood pressure (BP) is the cornerstone of hypertension management. The objectives of this study were to quantify the effect of medical personnel presence during BP measurement by automated oscillometric BP (AOBP) and to compare resting office BP by AOBP to daytime average BP by 24‐h ambulatory BP monitoring (ABPM). This study is a prospective randomized cross‐over trial, conducted in a referral population. Patients underwent measurements of casual and resting office BP by AOBP. Resting BP was measured as either unattended (patient alone in the room during resting and measurements) or as partially attended (nurse present in the room during measurements) immediately prior to and after 24‐h ABPM. The primary outcome was the effect of unattended 5‐min rest preceding AOBP assessment as the difference between casual and resting BP measured by the Omron HEM 907XL. Ninety patients consented and 78 completed the study. The mean difference between the casual and Omron unattended systolic BP was 7.0 mm Hg (95% confidence interval [CI] 4.5, 9.5). There was no significant difference between partially attended and unattended resting office systolic BP. Resting office BP (attended and partially attended) underestimated daytime systolic BP load from 24‐h ABPM. The presence or absence of medical personnel does not impact casual office BP which is higher than resting office AOBP. The requirement for unattended rest may be dropped if logistically challenging. Casual and resting office BP readings by AOBP do not capture the complexity of information provided by the 24‐h ABPM.

Randomized Controlled Trial Comparing Automated Office Blood Pressure Readings After Zero or Five Minutes of Rest.

[Figure: see text].

KEEP THE FIRST READING: AN ARGUMENT FOR THE IMPORTANCE OF THE FIRST OFFICE BLOOD PRESSURE READING IN CHILDREN

Objective: Lately, clinicians are using oscillometric devices with repeated blood pressure (BP) measurements (on the same occasion) to diagnose hypertension in children. It is unclear which of these measurements, or which combination of measurements, is the most predictive of ambulatory hypertension. Our objective was to determine which measurements of office BP correlate best with the 24-hour automated BP (ABPM). Design and method: We consecutively enrolled all pediatric patients, aged 1–18 years, who underwent ABPM in the last 3 years at The Children's Hospital of Eastern Ontario; all patients also had 3 consecutive oscillometric office blood pressure readings at the same time. We compared the first, second, and third and the average of all three measurements as well as the average of the last 2 readings with daytime BP from ABPM. All BP readings were converted to Z-scores based on published, normative paediatric data for office and ABPM. Results: Two-hundred and forty-five children (male=133) were included in the study. The median [IQR] of first, second and third systolic BP Z-scores (SBPz) were 2.29[1.44,3.21], 1.91[1.13,2.72] and 1.65[0.82, 2.47], respectively, and all were significantly different from one another (p &lt; 0.001). The largest difference/effect size was noted between the first and third measurement of SBPz (Cohen-d 0.51). Similar differences were observed in diastolic blood pressure Z-scores (DBPz), with medians [IQR] of 0.97[0.00, 1.87], 0.77[-0.19, 1.75] and 0.55[-0.37, 1.54] respectively (p &lt; 0.001, Cohen-d between first and third reading 0.32). On multivariate analysis, the only significant predictor of systolic daytime BP was the first office systolic BP reading (p = 0.001, relative importance 43%). Similarly, the only significant predictor of diastolic daytime BP was the first office diastolic BP reading (p &lt; 0.001, relative importance 43%). The first office SBPz and DBPz were also the best predictors of daytime systolic (ABPM SBPz &gt; 1.65) and diastolic (ABPM DBPz &gt; 1.65) hypertension on ROC with area under the curve (AUC) analysis (SBPz AUC = 0.69, DBPz AUC = 0.81). Conclusions: We observed significant differences between first, second and third office BP measurements. The first office systolic and diastolic BP readings appear to be the best predictors of ABPM daytime systolic and diastolic BP.