[The good use of home blood pressure monitoring. Consensus document]. / Document de consensus. Du bon usage de l'automesure tensionnelle.

Self or home blood pressure measurement (HBPM) is increasingly popular. Its prognostic value and clinical interest in the diagnosis and follow-up of hypertension are well established. In addition, experts widely agree on the fact that it improves hypertension management and therapeutic compliance. In particular, HBPM often allows to detect white coat hypertension (to be confirmed by 24-hour ambulatory blood pressure measurement). Unfortunately, a large part of HBPM devices in the European Union have not fulfilled independent validation criteria. Furthermore, many patients buy and use such devices without medical supervision. This consensus document summarizes the advantages and disadvantages of HBPM and the conditions of a proper use, in agreement with the recent European and American guidelines.

[Somatic investigation of psychiatric patients newly admitted to Flemish general psychiatric hospitals]. / Somatisch onderzoek bij nieuw opgenomen psychiatrische patiënten in Vlaamse algemene psychiatrische ziekenhuizen.

BACKGROUND: In Flanders there is as yet very little consensus concerning the extent and content of somatic investigations available to and conducted on patients newly admitted to psychiatric hospitals. AIM: To obtain an overview of the numbers and specialisms of medical-somatic staff at Flemish general psychiatric hospitals, the equipment available and the somatic routine examinations regularly requested. METHOD: We compiled a questionnaire about current hospital policy concerning the diagnosis of physical illnesses in newly admitted patients and the availability of diagnostic facilities. We submitted the questionnaires to 20 Flemish psychiatrist hospitals. RESULTS: The commonest type of medical equipment available at these psychiatric hospitals consisted of ECG, X-ray and ultrasonic devices. The routine examinations that were requested most frequently were blood and urine tests, ECG'S, clinical examinations, and X-rays of the thorax. The numbers and specialisms of somatic doctors at these hospitals vary from one hospital to the next. Sometimes a hospital does not have any somatic doctors at all. CONCLUSION: The general psychiatric hospitals in Flanders do not have a uniform policy concerning somatic examinations on newly admitted patients. The equipment and the numbers and specialisms of the medical-somatic staff vary from one hospital to another. It seems reasonable that extra investigations such as blood tests, ECG's and thorax X-rays should be conducted when case histories and clinical examinations indicate that such testing may be useful.

Prognostic significance of blood pressure measured in the office, at home and during ambulatory monitoring in older patients in general practice.

The purpose of the study was to assess the prognostic significance of out-of-the-office blood pressure (BP) measurement in older patients in general practice, and to compare the results for BP measured in the office, at home and during 24-h ambulatory monitoring. All registerd patients who were 60 years or older were eligible for the study, except when bedridden, demented or admitted in a home for sick elderly people, or when they had suffered a myocardial infarction or stroke. After baseline measurements in 1990-1993, incidence of major cardiovascular events (cardiovascular death, myocardial infarction and stroke) was ascertained in 2002-2003 and related to the BPs by use of multivariate Cox regression analysis. Age of the 391 patients averaged 71+/-9 years; 40% were men. During median follow-up of 10.9 years, 86 patients (22%) suffered a cardiovascular event. The adjusted relative hazard rate, associated with a 1 s.d. increment in systolic BP was 1.13 for office BP (NS), and, respectively, 1.32, 1.33 and 1.42, for home, daytime and night time BP (P< or =0.01 for all). Results were similar for diastolic BP. The prognostic significance of all out-of-the-office BPs was independent of office BP. The prognostic value of home BP was equal to (systolic) or even better (diastolic) than that of daytime BP. Night time BP predicted cardiovascular events independent of all other BPs. Prognosis of white-coat hypertension was similar to that of true normotension, but better than in sustained hypertension. In conclusion, the prognostic value of home BP is better than that of office BP in older patients in primary care, and is at least equal to that of daytime ambulatory BP. The prognosis of patients with white-coat hypertension is similar to that of true normotensives.

The international database of self-recorded blood pressures in normotensive and untreated hypertensive subjects.

OBJECTIVES: To pool data from individual subjects in an attempt to determine an operational threshold for making clinical decisions based on the self-recorded blood pressure (SRBP) and to examine how many hypertensive subjects, diagnosed by conventional blood pressure (CBP) measurement, would have a self-recorded blood pressure within the normotensive range if the proposed thresholds were applied. DATA SOURCES: Thirteen research groups studied 4668 untreated subjects. RESULTS: In total 2401 subjects were normotensive, 494 were borderline hypertensive and 1773 were definitely hypertensive. Hypertension had been diagnosed from the mean of 1-6 (median 3) CBP measurements obtained during 1-3 (median 1) visits. The reference values for SRBP measurements determined from the 95th percentiles of the distributions for normotensive subjects were 137 mmHg systolic and 85 mmHg diastolic. Of the subjects with systolic hypertension, 16% had systolic SRBP

For how many days should blood pressure be measured at home in older patients before steady levels are obtained?

This study investigated the period of time that blood pressure (BP) should be measured at home in older patients in order to obtain steady BP values. Thirty-six men and 38 women (> or =60 years) were recruited at one family practice. At one office visit the family physician measured supine, sitting and standing BPs three times consecutively in each position. During 10 consecutive days, BP was measured at home five times daily. The supine and standing BPs were measured once in the morning and in the evening and the sitting BP once at noon. These home BP values were averaged over the first day (1-day), over the first 3 days (3-day) and all 10 days (10-day) of measurements. In both the supine (-5.1 mm Hg) and sitting (-3.8 mm Hg) positions the 10-day average systolic home BP was significantly lower than the corresponding office BP. The opposite was observed for the 10-day average standing home BP values (+7.3/+3.4 mm Hg). Comparison of the 3-day and 10-day average home BP values showed only a significantly lower 10-day than 3-day systolic BP level in the supine position (-1.1 mm Hg, 95% CI -1.9 to -0.2 mm Hg). Repeated measures ANOVA, showed a small but significant decrease over time only for the supine systolic home BP (-0.29 mm Hg per day, 95% CI -0.49 to -0.08 mm Hg per day). We conclude that in older subjects, 3 days of home measurements may suffice to obtain steady values for the sitting and standing BPs. A longer interval might be required for the supine BP.

Antihypertensive therapy in older patients with isolated systolic hypertension: the Syst-Eur experience in general practice. The Syst-Eur Investigators.

BACKGROUND AND OBJECTIVE: This interim report from the Syst-Eur trial investigated the level of blood pressure control achieved during the double-blind period in patients followed in general practices. METHODS: In the Syst-Eur trial elderly patients (60 years or older) with isolated systolic hypertension were randomized to either active or placebo treatment. Active treatment consisted of nitrendipine combined with enalapril and/or hydrochlorothiazide to reduce systolic pressure to < 150 mmHg and by > or = 20 mmHg. Matching placebos were used in the control group. RESULTS: This analysis was restricted to patients of general practitioners who had been followed for at least 12 months. The placebo (N = 204) and active treatment (N = 217) groups had similar characteristics at randomization. At one year, the difference in sitting pressure between the two treatment groups was 10 mmHg systolic and 4 mmHg diastolic. Fewer patients remained on monotherapy in the placebo than in the active treatment group and on placebo the second and third line medications were started earlier. Nitrendipine tablets were discontinued in 10 patients on placebo and in 21 patients assigned to active treatment (P < 0.001 for all comparisons). CONCLUSIONS: A significant blood pressure reduction can be achieved and maintained in older patients with isolated systolic hypertension followed by general practitioners. Whether this blood pressure reduction results in a clinically meaningful decrease of cardiovascular complications is under investigation.

Antihypertensive therapy in older patients with isolated systolic hypertension: the Syst-Eur experience in general practice

Background and objective. This interim report from the Syst-Eur trial investigated the level of blood pressure control achieved during the double-blind period in patients followed in general practices. Methods. In the Syst-Eur trial elderly patients (60 years or older) with isolated systolic hypertension were randomized to either active or placebo treatment. Active treatment consisted of nitrendipine combined with enalapril and/or hydrochlorothiazide to reduce systolic pressure to Results. This analysis was restricted to patients of general practitioners who had been followed for at least 12 months. The placebo (N = 204) and active treatment (N = 217) groups had similar characteristics at randomization. At one year, the difference in sitting pressure between the two treatment groups was 10 mmHg systolic and 4 mmHg diastolic. Fewer patients remained on monotherapy in the placebo than in the active treatment group and on placebo the second and third line medications were started earlier. Nitrendipine tablets were discontinued in 10 patients on placebo and in 21 patients assigned to active treatment (P Conclusions. A significant blood pressure reduction can be achieved and maintained in older patients with isolated systolic hypertension followed by general practitioners. Whether this blood pressure reduction results in a clinically meaningful decrease of cardiovascular complications is under investigation. Keywords. Antihypertensive treatment, general practice, isolated systolic hypertension, randomized clinical trial.

The ambulatory blood pressure in normotensive and hypertensive subjects: results from an international database.

OBJECTIVE: To delineate more precisely an operational threshold for making clinical decisions based on ambulatory blood pressure (ABP) measurement by studying the ABP in subjects who were diagnosed as either normotensive or hypertensive by conventional blood pressure (CBP) measurement. SUBJECTS: Twenty-four research groups recruited 7069 subjects. Of these, 4577 were normotensive (systolic CBP < or = 140 mmHg and diastolic CBP < or = 90 mmHg) and 1773 were hypertensive (systolic CBP > or = 160 mmHg and/or diastolic CBP > or = 90 mmHg). Of the latter, 1324 had systolic and 1310 had diastolic hypertension. RESULTS: Ninety-five percent of the normotensive subjects had a 24-h ABP below (systolic and diastolic, respectively) 133 and 82 mmHg. Of the patients with systolic hypertension, 24% had a 24-h systolic ABP of < 133 mmHg. Similarly, 30% of those with diastolic hypertension had a 24-h diastolic ABP of < 82 mmHg. The probability that hypertensive patients had a 24-h ABP below these thresholds was higher in women than in men, increased with age and was 2- to 4-fold greater if the CBP of the patient had been measured at only one visit and if fewer than 3 CBP measurements had been averaged to establish the diagnosis of hypertension. By contrast, for each 10-mmHg increment in systolic CBP, this probability decreased by 54% for the 24-h systolic ABP and by 25% for the 24-h diastolic ABP, and for each 5 mmHg increment in diastolic CBP it increased by 6 and 9%, respectively. CONCLUSION: The ABP distributions of the normotensive subjects included in the present international database were not materially different from those in previous reports in the literature. One-fifth to more than one-third of the hypertensive patients had an ABP which was below the 95th centile of the ABP in normotensive subjects, but this proportion decreased if the hypertensive patients had shown a higher CBP upon repeated measurement. The prognostic implications of elevated CBP in the presence of normal ABP remain to be determined.

Ambulatory blood pressure in normotensive and hypertensive subjects: results from an international database.

OBJECTIVE: To delineate more precisely an operational threshold for making clinical decisions based on ambulatory blood pressure (ABP) measurement by studying the ABP in subjects who were diagnosed as either normotensive or hypertensive by conventional blood pressure (CBP) measurement. SUBJECTS: Twenty-four research groups recruited 7069 subjects. Of these, 4577 were normotensive (CBP < or = 140/90 mmHg), 719 were borderline hypertensive (systolic CBP 141-159 mmHg or diastolic CBP 91-94 mmHg) and 1773 were definitely hypertensive. Of the subjects in the last of these categories, 1324 had systolic hypertension (systolic CBP > or = 160 mmHg) and 1310 had diastolic hypertension (diastolic CBP > or = 95 mmHg). Combined systolic and diastolic hypertension was present in 861 subjects. Hypertension had been diagnosed from the mean of two to nine (median two) CBP measurements obtained at one to three (median two) visits. RESULTS: The 95th centiles of the ABP distributions in the normotensive subjects were (systolic and diastolic, respectively) 133 and 82 mmHg for 24-h ABP, 140 and 88 mmHg for daytime ABP and 125 and 76 mmHg for night-time ABP, respectively. Of the subjects with systolic hypertension, 24% had 24-h systolic ABP < 133 mmHg. Similarly, 30% of those with diastolic hypertension had 24-h diastolic ABP < 82 mmHg. The probability that hypertensive subjects had 24-h ABP below these thresholds tended to increase with age and was two- to fourfold greater if the CBP of the subject had been measured at only one visit and if fewer than three CBP measurements had been averaged for establishing the diagnosis of hypertension. By contrast, for each 10-mmHg increment in systolic CBP, this probability decreased by 54% for 24-h systolic ABP and by 26% for 24-h diastolic ABP, and for each 5-mmHg increment in diastolic CBP it decreased by 6 and 9%, respectively. In comparison with 24-h ABP, the overlap in the daytime and night-time ABP between normotensive and hypertensive subjects was of similar magnitude and was influenced by the same factors. CONCLUSIONS: The ABP distributions of the normotensive subjects included in the present international database were not materially different from those in previous reports in the literature. One-fifth to more than one-third of hypertensive subjects had an ABP which was below the 95th centile of the ABP of normotensive subjects, but this proportion decreased if the hypertensive subjects had shown a higher CBP upon repeated measurement. The prognostic implications of elevated CBP in the presence of normal ABP remain to be determined.

Nitrendipine in older patients with isolated systolic hypertension: second progress report on the SYST-EUR trial.

This report from the double-blind placebo-controlled SYST-EUR trial investigated whether modern antihypertensive drugs are suitable for maintaining long-term BP control in older (> or = 60 years of age) subjects with isolated systolic hypertension (SBP 160-219 mmHg and DBP < 95 mmHg). Active treatment consisted of nitredipine (10-40 mg/day) with the possible addition of enalapril (5-20 mg/day) and hydrochlorothiazide (12.5-25 mg/day), if necessary to reduce SBP to < 150 mmHg and by > or = 20 mmHg. Matching placebos were used in the control group. This analysis was restricted to 18 months of follow-up. The placebo (n = 456) and active treatment (n = 485) groups had similar characteristics at randomisation (sitting pressure 176/85 mmHg; age 73 years). SBP fell (P < 0.001) on average 10 mmHg more on active treatment than on placebo and DBP 4 mmHg more. Fewer patients remained on monotherapy in the placebo than in the active treatment group (P < 0.001); on placebo the second and third line medications were started earlier (P < 0.001). Nitrendipine tablets were discontinued in nine patients on placebo and in 29 patients assigned to active treatment (P < 0.001). In conclusion, a significant BP reduction can be achieved and maintained in older patients with isolated systolic hypertension treated with a calcium antagonist (associated with a converting-enzyme inhibitor and a thiazide, where necessary). Whether this BP reduction results in a clinically meaningful decrease of cardiovascular complications is under investigation.

Relationship between blood pressure measured in the clinic and by ambulatory monitoring and left ventricular size as measured by electrocardiogram in elderly patients with isolated systolic hypertension.

OBJECTIVE: To assess the additional diagnostic precision conferred by ambulatory blood pressure monitoring on clinic blood pressure measurement in evaluating the severity of isolated systolic hypertension. METHODS: The association between left ventricular size as determined by ECG voltages [R-wave voltages in lead V5 (RV5) and S-wave voltages in lead V1 (SV1)] and blood pressure as assessed by clinic measurements and ambulatory blood pressure monitoring was studied in 97 elderly patients included in the placebo run-in phase of the Syst-Eur trial. The additional diagnostic precision conferred by ambulatory monitoring on clinic blood pressure measurements was assessed by relating the residual ambulatory blood pressure level to the ECG-left ventricular size. The residual ambulatory blood pressure level was calculated by subtracting the predicted ambulatory blood pressure level for each patient (using the linear regression equation relating both techniques for the group) from the observed ambulatory blood pressure. RESULTS: Clinic systolic blood pressure was on average 20 mmHg higher (P < 0.001) than daytime ambulatory blood pressure while diastolic blood pressure was similar with both techniques. The sum of SV1 + RV5 was significantly related to clinic systolic pressure (r = 0.25), and 24-h (systolic, r = 0.37; diastolic, r = 0.29), daytime (systolic, r = 0.30; diastolic, r = 0.19) and night-time (systolic, r = 0.33; diastolic, r = 0.28) ambulatory blood pressure levels. These findings were not affected by adjustment for gender, age and the body mass index. The sum of SV1 + RV5 was significantly related to the residual 24-h (systolic, r = 0.30; diastolic, r = 0.31), daytime systolic (r = 0.20) and night-time (systolic, r = 0.31; diastolic, r = 0.29) ambulatory blood pressure monitoring levels. CONCLUSION: Ambulatory blood pressure monitoring adds to the diagnostic precision of clinic blood pressure measurement in assessing the severity of hypertension in this population. The ongoing side project on ambulatory blood pressure monitoring in the Syst-Eur study should establish whether these findings hold true for morbidity and mortality.

[SYST-EUR: a multicenter trial of treatment of systolic hypertension in aged subjects. An initial report]. / SYST-EUR un essai multicentrique du traitement de l'hypertension systolique du sujet âgé. Premier rapport intermédiaire.

Syst-Eur is a multicentre placebo-controlled outcome trial, designed by the European Working Party on High Blood Pressure in the Elderly (EWPHE), to investigate the effect of antihypertensive treatment on the incidence of stroke in elderly patients with isolated systolic hypertension (ISH). Eligible patients must be at least 60 years old and have a systolic blood pressure averaging 160-219 mmHg with a diastolic blood pressure less than 95 mmHg. The present paper in an interim report on the first 316 patients randomized into this trial. The placebo (N = 170) and active treatment (N = 146) groups were similar at randomization with respect to age (73 +/- 8 years; mean +/- standard deviation), sitting blood pressure (178 +/- 12/85 +/- 7 mmHg), percentage men (34%) and percentage of patients with cardiovascular complications (29%). After randomization blood pressure fell more (p < 0.001) on active treatment than in the placebo group (19 +/- 20/6 +/- 10 mmHg versus 7 +/- 19/1 +/- 10 mmHg for the sitting blood pressure). This first interim report on the Syst-Eur trial demonstrates that a multinational trial in elderly patients with ISH is feasible and that a significant blood pressure difference between the 2 treatment groups can be achieved and maintained. New centres are being recruited in order to randomize a total of 3,000 patients.

Ambulatory blood pressure monitoring in elderly patients with isolated systolic hypertension.

OBJECTIVES: This study compared clinic and ambulatory blood pressure measurement and the reproducibility of these measurements in older patients with isolated systolic hypertension (ISH). PATIENTS: Eighty-seven patients aged greater than or equal to 60 years with ISH on clinic measurement were followed in the placebo run-in phase of the Syst-Eur trial. METHODS: Clinic blood pressure was defined as the mean of two blood pressure readings on each of three clinic visits (six readings in total). Ambulatory blood pressure was measured over 24 h using non-invasive ambulatory blood pressure monitors. RESULTS: Daytime ambulatory systolic pressure was, on average, 21 mmHg lower than the clinic blood pressure, whereas diastolic pressure was, on average, similar with both techniques of measurement. In the 42 patients who had repeat measurements, clinic blood pressure levels nad the amplitude of the diurnal blood pressure profile (fitted by Fourier analysis) were equally reproducible. However, both were less reproducible than ambulatory blood pressure levels. The repeatability coefficients, expressed as per cent of near maximum variation (four times the standard deviation of a given measurement), were 52% and 45% for the clinic systolic and diastolic pressures, 56% and 42% for the amplitude of the diurnal profile, and 29% and 26% for mean 24-h pressures. CONCLUSIONS: In older patients with ISH, clinic and ambulatory systolic blood pressure measurements may differ largely: the prognostic significance of this difference remains to be elucidated. Furthermore, in these patients the level of pressure is more reproducible by daytime ambulatory blood pressure measurement than by clinic measurement.

Mean and range of the ambulatory pressure in normotensive subjects.

To perform a meta-analysis of published reports in an attempt to determine the mean and range of normal ambulatory blood pressure (BP), 23 studies including a total of 3,476 normal subjects were reviewed. Most studies were compatible with a mean 24-h BP in the range of 115-120/70-75 mmHg, a mean day time BP of 120-125/75-80 mmHg, and a mean night time BP of 105 to 110/60 to 65 mmHg. With weighting for the number of subjects included in the individual studies, the 24-h BP averaged 118/72 mmHg, the day time BP 123/76 mmHg, and the night time BP 106/64 mmHg. The night/day pressure ratio averaged 0.87 for systolic and 0.83 for diastolic BP, with ranges across the individual studies from 0.79 to 0.92 and from 0.75 to 0.90, respectively. If the mean +/- 2 standard deviation interval in the various studies was considered normal, the range of normality was on average 97 to 139/57 to 87 mmHg for the 24-h BP, 101 to 146/61 to 91 mmHg for the day time BP, and 86 to 127/48 to 79 mmHg for the night time BP. Until the results of prospective studies on the relation between the ambulatory BP and the incidence of cardiovascular morbidity and mortality become available, the aforementioned intervals, which summarize the experience of 23 investigators, could serve as a temporary reference for clinical practice.

Twenty-four hour blood pressure monitoring in the Syst-Eur trial.

This article describes the objectives and protocol of a study on ambulatory blood pressure in elderly patients with isolated systolic hypertension. This study constitutes an optional side-project to the Syst-Eur trial. The multicentre Syst-Eur trial investigates whether antihypertensive treatment of elderly patients with isolated systolic hypertension will influence the incidence of stroke. Secondary endpoints include cardiovascular events, such as myocardial infarction. The main objective of the side-project is to investigate whether ambulatory blood pressure monitoring will improve the prediction of cardiovascular complications based on blood pressure measurement in the clinic. The side-project also provides the opportunity to evaluate the diurnal profile of blood pressure in elderly patients with isolated systolic hypertension randomized to placebo or active antihypertensive treatment.

Syst-Eur--a multicenter trial on the treatment of isolated systolic hypertension in the elderly: first interim report.

Syst-Eur is a multicenter placebo-controlled outcome trial designed by the European Working Party on High Blood Pressure in the Elderly to investigate the effect of antihypertensive treatment on the incidence of stroke in elderly patients with isolated systolic hypertension (ISH). Eligible patients must be at least 60 years old and have a systolic blood pressure averaging 160-219 mm Hg with a diastolic blood pressure less than 95 mm Hg. The present paper is an interim report on the first 316 patients randomized into this trial. The placebo (n = 170) and active treatment (n = 146) groups were similar at randomization with respect to age (73 +/- 8 years; mean +/- SD), sitting blood pressure (178 +/- 12 mm Hg systolic; 85 +/- 7 mm Hg diastolic), percentage of men (34%), and percentage of patients with cardiovascular complications (29%). After randomization blood pressure fell more (p less than 0.001) in patients on active treatment than in those in the placebo group (19 +/- 20 mm Hg systolic; 6 +/- 10 mm Hg diastolic vs. 7 +/- 19 and 1 +/- 10 mm Hg for sitting blood pressure). This first interim report on the Syst-Eur trial demonstrates that a multinational trial in elderly patients with ISH is feasible and that a significant blood pressure difference between the two treatment groups can be achieved and maintained. New centers are being recruited in order to randomize a total of 3,000 patients.

Methods for describing the diurnal blood pressure curve.

Ambulatory blood pressure recordings supply information on the blood pressure variation during habitual daily activities and sleep. Whether the circadian blood pressure curve is modulated by an endogenous clock or whether the diurnal fluctuations in blood pressure are mainly or exclusively determined by the pattern of activity remains disputed. Whatever the underlying mechanism, most experts agree that it still remains to be ascertained whether the blood pressure profile can help in unraveling the pathophysiology of hypertension and determining a subject's cardiovascular risk. The methods for parametrizing the diurnal blood pressure curve in individual subjects, summarized in this article, may provide summary statistics for larger groups of individuals or for the population at large.

An inventory of studies on ambulatory blood pressure in large groups of subjects.

We made an inventory of 19 studies that have been or are being undertaken to better characterize the distribution of ambulatory blood pressure in the population at large or in larger groups of individuals selected from the population. No study was without some degree of selection in the recruitment of its subjects, but none of the subjects was selected or excluded on the basis of ambulatory blood pressure. These studies could provide the data required to define more precise, age- and sex-specific, diagnostic criteria for ambulatory blood pressure measurement in day-to-day clinical practice.