Home blood pressure monitoring alone vs. combined clinic and ambulatory measurements in following treatment-induced changes in blood pressure and organ damage.

BACKGROUND: Out-of-office blood pressure (BP) measurement using home BP (HBP) or ambulatory BP (ABP) monitoring is often necessary for the accurate evaluation of hypertension. These methods have several similarities but also have major differences. Therefore, they are regarded as complementary, and there is uncertainty on how they should be applied in clinical practice. This study compared hypertension management based on clinic and ABP measurements or on HBP measurements alone. METHODS: Untreated subjects with elevated BP were randomized to treatment initiation and titration based on clinic and ABP measurements or on HBP measurements alone. Target organ damage was assessed at baseline and after 1 year of treatment with echocardiographic left ventricular mass index (primary endpoint), pulse wave velocity, and urinary albumin excretion. RESULTS: A total of 145 subjects were randomized, and 116 completed the study (mean age = 50.7±10.5 years; 69 men (59%); mean follow-up = 13.4±1.4 months). There was no difference between the 2 arms in treatment-induced change in left ventricular mass index (mean difference = 0.50±1.11 g/m2; 95% confidence interval (CI) = -1.70 to 2.70). Moreover, there was no difference between the 2 arms in treatment-induced changes in pulse wave velocity (mean difference = -0.16±0.42 m/s; 95% CI = -0.99 to 0.66), urinary albumin excretion (mean difference = -0.85±4.28 mg/dl; 95% CI = -9.37 to 7.66), HBP and ABP levels, and hypertension control rates. CONCLUSIONS: These data suggest that HBP monitoring alone is as reliable as combined clinic and ABP measurements in monitoring the effects of antihypertensive drug treatment on BP and preclinical target organ damage.

Feasibility and reproducibility of noninvasive 24-h ambulatory aortic blood pressure monitoring with a brachial cuff-based oscillometric device.

BACKGROUND: Accumulating evidence suggests the potential superiority of office aortic blood pressure (BP) over brachial in the management of arterial hypertension. The noninvasive aortic 24-h ambulatory brachial BP monitoring (ABPM) is potentially the optimal method for assessing BP profile. The objective of the present study was to investigate the feasibility and reproducibility to perform noninvasively 24-h aortic ABPM with a novel validated brachial cuff-based automatic oscillometric device (Mobilo-O-Graph) which records brachial BP and waveforms and assesses aortic BP via mathematical transformation. METHODS: Thirty consecutive subjects (mean age: 53.6 ± 11.6 years, 17 men) had a test-retest ABPM with at least 1-week interval. No modification of vasoactive drug treatment during the interval was allowed while similar 24-h activity during both recording days was recommended. RESULTS: The average number of valid readings for brachial vs. aortic BP were 69.9 ± 10.4 vs. 58.0 ± 13.3 in the initial 24-h assessment (P < 0.001) and 68.3 ± 10.8 vs. 56.4 ± 13.6 in the repeat assessment (P < 0.001). No differences in average 24 h aortic BP values were observed between the two assessments (systolic blood pressure (SBP) 115.9 ± 7.7 vs. 115.1 ± 6.0 mm Hg, respectively, P = 0.48, and diastolic 79.7 ± 7.4 vs. 79.2 ± 8.7, P = 0.54). Reproducibility indices of aortic pressure including, intraclass coefficient of variation (SBP: 0.80 (95% confidence interval 0.58-0.90); diastolic: 0.92 (0.83-0.96)) and s.d. of differences (SBP/diastolic: 6.0/4.5 mm Hg) indicated acceptable reproducibility. The Bland-Altman plots indicated no evidence of systemic bias. CONCLUSIONS: In conclusion, these data suggest that noninvasive 24-h ABPM is feasible and provides reproducible values. Future studies should validate the prognostic ability of 24-h aortic hemodynamics.

Sodium handling is associated with liver function impairment and renin-aldosterone axis activity in patients with preascitic cirrhosis without hyponatremia.

BACKGROUND: In cirrhotic patients awaiting liver transplantation, serum sodium concentration is related to prognosis. However, abnormalities in sodium homeostasis are evident even in the early preascitic stage of cirrhosis. We aimed to investigate whether parameters of renal sodium handling (serum sodium, urinary sodium and fractional exertion of sodium (FeNa%) correlate with markers of liver function and renin-aldosterone axis activity in patients with preascitic cirrhosis without hyponatremia. METHODS: Patients with preascitic cirrhosis without hyponatremia underwent routine blood and urine laboratory tests, including markers of liver function impairment and sodium homeostasis. RESULTS: Thirty eight cirrhotic patients (22 men) with mean age of 57.3±12.2 (SD) years were included. Twenty six and twelve patients were at Child-Pugh stage A and B cirrhosis respectively. Eighteen patients had a Model for End-stage Liver Disease (MELD) score of ≤9 and twenty had MELD >9. Serum sodium was found to differ significantly between Child-Pugh stage A and B cirrhotics (mean 142.8±2.0 mmol/L vs. 140.5±3.3 mmol/L, p<0.05). Serum sodium was also found to differ significantly between patients with MELD score ≤9 and >9 (mean 143.3±2.0 mmol/L vs. 140.9±2.8 mmol/L, respectively, p<0.01). Serum sodium correlated negatively with the international normalized ratio (INR) (r=-0.51, p<0.01), aldosterone (r=-0.40, p<0.05), Child-Pugh and MELD scores (r=-0.34, p<0.05 and r=-0.45, p<0.05 respectively). FeNa% correlated negatively with renin and aldosterone (r=-0.56, p<0.001 and r=-0.50, p<0.01 respectively). CONCLUSION: Serum sodium concentration is a good surrogate marker of liver function impairment not only in late-stage liver cirrhosis before transplantation but also in the early preascitic stage.

Relationship of 24-hour ambulatory blood pressure and heart rate with markers of hepatic function in cirrhotic patients.

BACKGROUND: There is evidence that in cirrhotic patients, certain hemodynamic parameters, such as blood pressure and heart rate, are related to the severity of liver disease. This study investigated whether non-invasive 24-hour ambulatory blood pressure and heart rate are more closely associated with markers of liver disease severity than conventional office measurements. METHODS: Ambulatory patients with cirrhosis underwent office blood pressure and heart rate measurements, 24-hour ambulatory blood pressure monitoring and blood laboratory tests. RESULTS: Fifty-one patients (32 men, mean age 57.4 ± 11.3 years) completed the study. Twenty six patients had compensated liver cirrhosis (group A) and 25 patients had more advanced liver disease (group B). Group A and B patients differed significantly both in ambulatory asleep diastolic blood pressure (p < 0.05) and office diastolic blood pressure (p < 0.01), which were lower in more advanced liver disease. Office blood pressure and heart rate correlations were similar to or even stronger than ambulatory ones. Ambulatory blood pressure and heart rate awake-asleep variation (dipping) showed a relatively flat pattern as markers of liver dysfunction were deteriorating. The strongest correlations were found with both ambulatory and office heart rate, which increased as indicators of severity of liver disease were worsening. CONCLUSIONS: Heart rate seems to be a more reliable marker of ongoing liver dysfunction than blood pressure. Evaluation of blood pressure and heart rate with 24-hour ambulatory measurement does not seem to offer more information than conventional office measurements.

Validation of the Microlife Watch BP Office professional device for office blood pressure measurement according to the International protocol.

OBJECTIVE: To assess the accuracy of oscillometric and auscultatory blood pressure (BP) measurement taken using the professional electronic device Microlife Watch BP Office according to the European Society of Hypertension International Protocol. METHODS: Thirty-three participants were included for the assessment of each measurement mode (oscillometric and auscultatory). Simultaneous BP measurements were taken by two observers (mercury sphygmomanometers) four times, sequentially with three measurements taken using the tested device. Absolute observer device BP differences were calculated. For each participant the number of measurements with a difference within 5 mmHg was calculated. RESULTS: In phase 1 the device produced 32, 40 and 40 oscillometric systolic BP (SBP) measurements within 5, 10 and 15 mmHg, respectively and diastolic BP (DBP) 30, 40 and 43 (for auscultatory SBP 29, 42, 45 and DBP 33, 43, 45). In phase 2.1 the device produced 71, 90 and 96 SBP measurements within 5, 10 and 15 mmHg, respectively and DBP 71, 88 and 97 (for auscultatory SBP 72, 96, 99 and DBP 83, 96, 99). Twenty-four participants had at least two of their SBP differences within 5 mmHg and one participant had no difference within 5 mmHg, and DBP 23 and three participants, respectively (for auscultatory SBP 29 and 0 and DBP 29 and 1). Mean SBP difference was -1.4+/-6.3 mmHg and DBP -0.8+/-6.0 mmHg (auscultatory SBP -1.8+/-4.5 and DBP -0.4+/-4.0). CONCLUSION: The Microlife Watch BP Office device used in the oscillometric or the auscultatory mode fulfills the validation criteria of the International protocol and therefore can be recommended for clinical use.

Automated device that complies with current guidelines for office blood pressure measurement: design and pilot application study of the Microlife WatchBP Office device.

OBJECTIVE: Current guidelines for office blood pressure (BP) measurement recommend mercury devices, both arms measurement in the initial assessment and at least duplicate measurements at follow-up visits. This study presents the design and a pilot application study of an automated device that fulfils American, European, and International guidelines for office BP measurement. DESIGN AND FUNCTIONS: The Microlife WatchBP Office is a professional electronic mercury-free device with three function modes designed for: (a) initial assessment: triplicate automated simultaneous oscillometric both arms measurement at 60-s intervals and when there is a consistent interarm difference more than 20 mmHg systolic and/or more than 10 mmHg diastolic, the arm with the higher BP is indicated. (b) Follow-up assessment: triplicate automated oscillometric single arm measurements at 60-s intervals and their average is displayed. (c) Auscultatory measurement: by an observer using a stethoscope and a digital countdown BP display for patients with arrhythmias and other individuals in whom the oscillometric measurement is not accurate. PILOT APPLICATION STUDY: The 'initial assessment' mode was applied by three physicians in 63 patients (189 readings). Average interarm systolic BP difference was 0.04+/-5.1 mmHg and diastolic 0.4+/-3.2 mmHg. A value more than 10 mmHg interarm difference in nine systolic BP readings (5%) and three (2%) diastolic. No patient had a consistent interarm difference more than 10 mmHg in all three or two of the three readings. CONCLUSION: The Microlife WatchBP Office professional device fulfils current international requirements for office BP measurement and seems to overcome several limitations of this method when applied in clinical practice.

Validation of the A&D UM-101 professional hybrid device for office blood pressure measurement according to the International Protocol.

OBJECTIVE: Assessment of the accuracy of the A&D UM-101 mercury-free professional device for auscultatory blood pressure (BP) measurement according to the European Society of Hypertension International Protocol. Further to auscultation, the device has a button to mark readings during deflation. METHODS: Fifteen adults were included in phase 1 and another 18 in phase 2. Simultaneous BP measurements were taken by two observers (connected mercury sphygmomanometers) four times, sequentially with three measurements using the tested device (two connected tested devices, one used with and the other without the mark button). RESULTS: In phase 1, the device produced 44/45/45 measurements within 5/10/15 mmHg, respectively, for systolic BP (SBP) and 39/43/45 for diastolic (DBP). In phase 2.1, 87/97/99 measurements within 5/10/15 mmHg, respectively, for SBP, and 91/97/99 for DBP (using the mark button 65/93/98 for SBP and 76/96/99 for DBP). In phase 2.2, 29 participants had at least two of their SBP differences within 5 mmHg and none had any differences within 5 mmHg, whereas 32 and none, respectively, for DBP (with mark 24/4 participants for SBP; 29/1 for DBP). Mean SBP differences were -1.5+/-3.5 mmHg and DBP -1.3+/-3.0 (with mark -3.6+/-4.2 and -2.8+/-3.7). The difference in SBP measured by the tested device with versus without using the mark button was 3.0+/-3.3 mmHg (P<0.001) and DBP 1.9+/-2.5 mmHg (P<0.001). CONCLUSION: The device comfortably passed the validation protocol requirements. Using the mark button, the device, however, failed to meet the validation criteria. Therefore, it is recommended for clinical use without using the mark button.

Masked hypertension assessed by ambulatory blood pressure versus home blood pressure monitoring: is it the same phenomenon?

BACKGROUND: Masked hypertension is defined as normal clinic blood pressure (CBP) and elevated out-of-clinic blood pressure assessed using either self-monitoring of blood pressure (BP) by the patients at home (HBP) or ambulatory BP (ABP) monitoring. This study investigated the level of agreement between ABP and HBP in the diagnosis of masked hypertension. METHODS: Participants referred to an outpatient hypertension clinic had measurements of CBP (two visits), HBP (4 days), and ABP (24 h). The diagnosis of masked hypertension based on HBP (CBP <140/90 mm Hg and HBP > or =135/85) versus ABP (CBP <140/90 and awake ABP > or =135/85) was compared. RESULTS: A total of 438 subjects were included (mean age +/- SD, 51.5 +/- 11.6 years; 59% men and 41% women, 34% treated and 66% untreated). Similar proportions of subjects with masked hypertension were diagnosed by ABP (14.2%) and HBP (11.9%). In both treated and untreated subjects, the masked hypertension phenomenon was as common as the white coat phenomenon. Among 132 subjects with normal CBP, there was disagreement in the diagnosis of masked hypertension between the HBP and the ABP method in 23% of subjects for systolic and 30% for diastolic BP (kappa 0.56). When a 5-mm Hg gray zone for uncertain diagnosis was applied to the diagnostic threshold, the disagreement was reduced to 9% and 6% respectively. CONCLUSIONS: Similar proportions of subjects with masked hypertension are detected by ABP and HBP monitoring. Although disagreement in the diagnosis between the two methods is not uncommon, in the majority of these cases the deviation of the diagnostic BP above the threshold in not clinically important. Both ABP and HBP monitoring appear to be appropriate methods for the detection of masked hypertension.