How many blood pressure measurements should we take in the office?

No consensus has emerged among different guidelines concerning how many blood pressure (BP) measurements should be performed at office visits in the diagnosis of hypertension. The purpose of this study was to examine the compatibility of various multiple average office BP measurements and 24-h BP monitoring (ABPM) in patients followed up in the posthoc analysis of the Cappadocia hypertension cohort. A total 1158 office BP measurements by 207 patients were examined. The results were then classified as G1 (average of the 1st and 2nd BP), G2 (average of the 2nd and 3rd), G3 (average of the 2nd, 3rd, and 4th), G4 (average of the 2nd, 3rd, 4th, and 5th), and G5 (average of all five measurements). Compatibility between the average values in the groups and concomitant 24-h ABPM data was examined. While a significant difference was observed between daytime 24-h ABPM SBP and G1 (p = .002), no difference was found in the other groups. Office DBP approached the daytime 24-h ABPM values as the number of measurements in the five groups increased, although average office DBP data in all groups were higher than daytime 24-h ABPM DBP (p = .000 for all). In light of our study results, we recommend that three office BP measurements be performed and that the average of the 2nd and 3rd measurements be used for SBP, while in terms of DBP, we recommend that as many measurements as possible be taken without the 1st value being included in the average.

Comparison of outcomes for routine versus American Heart Association-recommended technique for blood pressure measurement (CORRECT BP): a randomised cohort study.

Background: Optimal clinical care, diagnosis and treatment requires accurate blood pressure (BP) values. The primary objective was to compare BP readings taken while adhering to American Heart Association (AHA) guidelines to those typical of routine clinical care. Specifically studied: the combined effect of feet flat on the floor, back supported, and arm supported with cuff at heart level, while adhering to other guideline recommendations. Methods: In this prospective, randomised, three-group cohort study, a modified cross-over design was applied in a primary care outpatient office setting in Columbus (OH, USA). Eligible participants were adults (aged ≥18 years) with an arm circumference of ≥18 cm and ≤42 cm who did not have a renal dialysis shunt or a previous or current diagnosis of atrial fibrillation. 150 recruited volunteers meeting the inclusion criteria were randomly randomised into the three groups. Group methodologies were BP readings taken on a fixed-height exam table followed by readings taken in an exam chair with adjustable positioning options (Group A), readings taken in the reverse order, chair then table (Group B), and both sets of readings in the exam chair (Group C). A rest period occurred before each set of readings. Group C was included for the purpose of obtaining an independent estimate of the order effect. The order in which the two types of readings (table vs chair) were taken was randomised. The primary outcome was the difference between the mean of three BP readings taken on the table and the mean of three readings taken in the chair. Findings: Between September and October, 2022, 150 participants were enrolled in the study; all 150 of whom completed testing: 48 in Group A, 49 in Group B, 53 in Group C. The mean systolic/diastolic BP (SBP/DBP) of readings taken on the table (Group A first readings, Group B second readings) were 7.0/4.5 mmHg higher than those taken in the chair (Group A second readings, Group B first readings); both statistically significant, p < 0.0001. These findings show that AHA-recommended positioning-feet flat on the floor, back supported, arm supported with the BP cuff at heart level-results in substantially lower BP values than improper positioning. The mean SBP/DBP of the first set of readings taken on the chair were 1.6/0.6 mmHg higher than for the second set of readings (Group C, included to estimate order effect). Interpretation: The observed benefit of proper positioning is sufficient to change the BP classification of several million patients from having hypertension to not having hypertension and therefore avoiding medication and/or intense follow-up. Funding: Midmark Corporation, Versailles, Ohio, USA.

Adiposity and Cardiac Defects: Pathophysiology and Etiology.

The worldwide obesity epidemic is well known, with most countries experiencing rises in obesity incidence since the 1980s. Obesity directly contributes to the occurrence of cardiovascular risk factors such as dyslipidemia, type 2 diabetes, hypertension, and sleep problems. Obesity, in addition to other cardiovascular risk factors, contributes to the development of cardiovascular disease (CVD) and cardiovascular disease mortality. Recent research suggests that abdominal obesity, as measured by waist circumference, is a risk factor for CVD that is independent of body mass index. As adipose tissue develops excessively, the individual's heart structure and function undergo a range of adaptations and changes. Obesity is a long-term metabolic disease that is linked to CVD, more hospitalizations, and more deaths. Even in the case of high blood pressure or a persistent structural heart problem, it is clear that when too much fat builds up, the structure and function of the heart change in a number of ways. In addition to its indirect effects, obesity has a number of direct and indirect effects on the cardiovascular system which makes it more likely for people to get sick or die. There may not be a direct link between total body fat and heart rate because the heart rate goes down when body fat percent goes up. High cardiac output in obese people is mostly caused by a rise in stroke volume to meet the metabolic needs of adipose tissue. Cardiomyopathy is caused by a direct effect of obesity on the heart. This is called adipositas cordis. Overweight and obesity can cause or be linked to a number of heart problems, such as coronary artery disease, cardiac arrest, and sudden death.

Impact of the 2022 American Heart Association pediatric ambulatory blood pressure monitoring statement on the diagnosis of hypertension.

BACKGROUND: The diagnosis of hypertension and hypertension-induced target organ injury by the 2022 American Heart Association (AHA) ambulatory blood pressure threshold as compared with 2014 AHA and 2016 European Society of Hypertension (ESH) thresholds has not been evaluated. METHODS: In a cross-sectional study (n = 291, aged 5-18 years, at a tertiary care outpatient clinic), we compared 2022 AHA with 2014 AHA and ESH thresholds (revised with 2018 adult ESH thresholds where applicable) to diagnose ambulatory hypertension (AH), and detect ambulatory arterial stiffness index (AASI) and left ventricular target organ injury (LVTOI). RESULTS: The 2022 AHA threshold diagnosed significantly more AH (53%) than the 2014 AHA (42%, p < 0.01) and ESH (36%, p < 0.001) thresholds. The 2022 AHA threshold demonstrated only a moderate agreement with the 2014 AHA (kappa (k) = 0.77) and ESH (k = 0.66) thresholds to diagnose AH. Adjusted logistic regression analysis found that only the 2022 AHA threshold predicted elevated AASI significantly (odds ratio 2.40, 95% CI 1.09, 5.25, p = 0.02; AUC 0.61, p < 0.01). In those with elevated AASI, more participants had AH by the 2022 AHA threshold (72%) than the 2014 AHA (46%, p = 0.02) and ESH (48%, p = 0.03) thresholds. AH defined by the 2022 AHA threshold continued to maintain higher odds, larger AUC, and higher sensitivity to identify LVTOI than the 2014 AHA and ESH thresholds; however, the difference did not reach a statistically significant level. CONCLUSIONS: AH defined by the 2022 AHA threshold diagnoses more children with hypertension and identifies more children with hypertension-induced target organ injury than the 2014 AHA and ESH thresholds. A higher resolution version of the Graphical abstract is available as Supplementary information.

European Society of Hypertension Guidelines 2023: Hipertensão arterial - Estamos indo em qual direção? / Europeah direction are we heading?n Society of Hypertension Guidelines 2023: Arterial hypertension - In which direction are we heading?

A cada nova edição de diretrizes, algumas recomendações se consolidam e outras surgem, à luz de novas evidências, mudando comportamentos, entendimentos e trazendo novas possibilidades e desafios. A nova Diretriz da Sociedade Europeia de Hipertensão (ESH) de 2023 apresenta-se coerente com outras que foram publicados na última década. Ao mesmo tempo em que se mostra conservadora em alguns tópicos, avança de maneira inovadora em outros pontos sensíveis. Embora ampla e abrangente, percebe-se que o foco principal converge para alguns poucos e importantes objetivos. A Diretriz da ESH 2023 propõe como objetivos centrais: 1. Determinação incansável para que se atinja a meta pressórica recomendada; 2. Atenção máxima contra a inércia terapêutica; 3. Usar de múltiplas estratégias para o melhor engajamento do paciente ao tratamento. Além disso, traz recomendações importantes nas áreas de mecanismos fisiopatológicos, diagnóstico, tratamento, acompanhamento e destaques em situações especiais. Logo abaixo, destaco alguns aspectos que considero relevante (AU).

With each new edition of guidelines, some recommendations are consolidated, and others emerge in the light of new evidence, changing behaviors and understandings and bringing new possibilities and challenges. The new 2023 European Society of Hypertension (ESH) Guidelines are consistent with others published in the last decade. While being conservative on some topics, it advances in an innovative way on other sensitive points. Although broad and comprehensive, the focus converges on a few important objectives. The ESH 2023 Guideline proposes as central objectives: 1. Tireless determination to reach the recommended blood pressure goal. 2. Maximum attention against therapeutic inertia. 3. Using multiple strategies for better patient engagement with treatment. In addition, it brings important recommendations in the areas of pathophysiological mechanisms, diagnosis, treatment, follow-up, and highlights in special situations. Below, I highlight some aspects that I consider relevant

Cost-accuracy and patient experience assessment of blood pressure monitoring methods to diagnose hypertension: A comparative effectiveness study.

Objectives: Studies of the diagnosis of hypertension have emphasized long-term cost-effectiveness analysis, but the patient experience and costs of blood pressure monitoring methods at the diagnosis stage remain unclear. We studied four diagnostic methods: a new 1 h-automated office blood pressure (BP) monitoring, office BP measurement, home BP monitoring, and awake-ambulatory BP monitoring. Methods: We carried out a comparative effectiveness study of four methods of diagnosing hypertension in 500 participants with a clinical suspicion of hypertension from three primary healthcare (PHC) centers in Barcelona city (Spain). We evaluated the time required and the intrinsic and extrinsic costs of the four methods. The cost-accuracy ratio was calculated and differences between methods were assessed using ANOVA and Tukey's honestly significant difference (HSD) post-hoc test. Patient experience data were transformed using Rasch analysis and re-scaled from 0 to 10. Results: Office BP measurement was the most expensive method (€156.82, 95% CI: 156.18-157.46) and 1 h-automated BP measurement the cheapest (€85.91, 95% CI: 85.59-86.23). 1 h-automated BP measurement had the best cost-accuracy ratio (€ 1.19) and office BP measurement the worst (€ 2.34). Home BP monitoring (8.01, 95% CI: 7.70-8.22), and 1 h-automated BP measurement (7.99, 95% CI: 7.80-8.18) had the greatest patient approval: 66.94% of participants would recommend 1 h-automated BP measurement as the first or second option. Conclusion: The relationship between the cost-accuracy ratio and the patient experience suggests physicians could use the new 1 h-automated BP measurement as the first option and awake-ambulatory BP monitoring in complicated cases and cease diagnosing hypertension using office BP measurement.

Clinical Application of Epithelial Sodium Channel (ENaC) as a Biomarker for Arterial Hypertension.

Arterial hypertension (HTN) is a global public health concern and an important risk factor for cardiovascular diseases and renal failure. We previously reported overexpression of ENaC on the plasma membrane of human platelets is a hallmark of HTN. In this double-blinded study of an open population (n = 167), we evaluated the sensitivity and specificity of a diagnostic assay based on gold nanoparticles (AuNPs) conjugated to an antibody against epithelial sodium channel (ENaC) expressed on platelets, which is detected using a fluorescent anti-ENaC secondary antibody and spectrofluorometry. Using the cutoff value for the AuNP-anti-ENaC assay, we confirmed the diagnosis for 62.1% of patients with clinical HTN and detected 59.7% of patients had previously undiagnosed HTN. Although some shortcomings in terms of accurately discriminating healthy individuals and patients with HTN still need to be resolved, we propose this AuNP-anti-ENaC assay could be used for initial screening and early diagnosis to critically improve opportune clinical management of HTN.

Adherence to the DASH diet by hypertension status in Mexican men and women: A cross-sectional study.

Improving dietary patterns is a cornerstone of the non-pharmacological management of hypertension. Evidence about the adherence to healthy dietary patterns at the population level is scarce. We aimed to analyze the adherence to the Dietary Approaches to Stop Hypertension (DASH) diet among Mexican men and women by hypertension status. We used data from the 2012 Mexican National Health and Nutrition Survey (n = 2560). Using self-reported diagnosis of hypertension and blood pressure measurements, we identified participants without, with undiagnosed, and diagnosed hypertension. We calculated DASH scores (total and dietary components) based on a single 24-hour recall and analyzed differences in adherence across hypertension status using sex-specific multivariable Poisson regression models. Overall, regardless of hypertension status, adherence to the DASH score was low, with 35% of men and 38% of women with diagnosed hypertension adhering to recommended guidelines; lower adherence was observed in men (21.8%) and women (27.2%) with undiagnosed hypertension, and with no hypertension (26.8% in men, 26.3% in women). In multivariable models for men, the prevalence of adherence to the total DASH diet was 29% lower in undiagnosed adults versus adults without hypertension (RP 0.71; 95%CI 0.50,0.99). Specifically, adherence to fruits, total dairy, and animal protein was lower in undiagnosed men. Among women, the adherence to the DASH diet was similar across hypertension status in multivariable models. Mexican adults had low adherence to DASH, regardless of hypertension status. Strategies to improve adherence to DASH are needed, focusing in patients with hypertension but also as a preventive measure for the population.

Diagnosis of hypertension: Ambulatory pediatric American Heart Association/European Society of Hypertension versus blood pressure load thresholds.

The agreement between the traditionally-used ambulatory blood pressure (ABP)-load thresholds in children and recently-recommended pediatric American Heart Association (AHA)/European Society of Hypertension (ESH) ABP thresholds for diagnosing ambulatory hypertension (AH), white coat hypertension (WCH), and masked hypertension (MH) has not been evaluated. In this cross-sectional study on 450 outpatient participants, the authors evaluated the agreement between previously used ABP-load 25%, 30%, 40%, 50% thresholds and the AHA/ESH thresholds for diagnosing AH, WCH, and MH. The American Academy of Pediatrics thresholds were used to diagnose office hypertension. The AHA threshold diagnosed ambulatory normotension/hypertension closest to ABP load 50% in 88% (95% CI 0.79, 0.96) participants (k 0.67, 95% CI 0.59, 0.75) and the ESH threshold diagnosed ambulatory normotension/hypertension closest to ABP load 40% in 86% (95% CI 0.77, 0.94) participants (k 0.66, 95% CI 0.59, 0.74). In contrast, the AHA/ESH thresholds had a relatively weaker agreement with ABP load 25%/30%. Therefore, the diagnosis of AH was closest between the AHA threshold and ABP load 50% (difference 3%, 95% CI -2.6%, 8.6%, p = .29) and between the ESH threshold and ABP load 40% (difference 4%, 95% CI -2.1%, 10.1%, p = .19) than between the AHA/ESH and ABP load 25%/30% thresholds. A similar agreement pattern persisted between the AHA/ESH and various ABP load thresholds for diagnosing WCH and MH. The AHA and ESH thresholds diagnosed AH, WCH, and MH closest to ABP load 40%/50% than ABP load 25%/30%. Future outcome-based studies are needed to guide the optimal use of these ABP thresholds in clinical practice.

Potential Impact of the New American High Blood Pressure Guidelines on Hypertension Prevalence in a Primary Health Care Unit in Rio de Janeiro - the LapARC Study

Abstract Background The new American Heart Association guidelines for hypertension (HT) proposed a reduction of the diagnostic cut-off point, leading to a substantial increase in the prevalence of HT. Objectives To assess the prevalence of HT determined by the traditional criteria, the AHA criteria, and home blood pressure monitoring (HBPM) in a population of young adults attending a primary healthcare unit, and its association with cardiovascular risk. Methods A cross-sectional population study on adults aged from 20 to 50 years attending a primary healthcare unit, in Rio de Janeiro, Brazil. Sociodemographic and anthropometric data, cardiovascular risk factors, office blood pressure and HBPM were registered. The diagnosis of HT was defined by traditional criteria (office BP ≥ 140 x 90 mmHg) and by the new (AHA) criteria (office BP ≥ 130 x 80 mmHg). Bivariate analysis was used for comparisons between the two diagnostic criteria, and Kappa coefficient was used to assess the agreement in diagnosis between office BP and HBPM. The level of significance adopted was 5% (p<0.05). Results A total of 472 individuals were evaluated (male: 39%; mean age: 38.5 ± 8.7 years). The prevalence of HT was 23.5% and raised to 41.1% with the new AHA criteria. The prevalence of HT using HBPM was 25.5%, but the diagnostic agreement was low (kappa=0.028) with changes in diagnosis in 18% of the cases. Conclusion The prevalence of HT almost doubled with the new AHA diagnostic criteria for HT. HBPM seemed to be an important instrument in HT diagnosis in this population. (Int J Cardiovasc Sci. 2021; [online].ahead print, PP.0-0)

Religious Leaders as Trusted Messengers in Combatting Hypertension in Rural Tanzanian Communities.

BACKGROUND: Hypertension is a growing public health emergency in rural sub-Saharan Africa. Based on the known influence of religious leaders in rural sub-Saharan Africa and our prior research, we explored perspectives of religious leaders on hypertension and potential strategies to improve hypertension control in their communities. METHODS: We conducted 31 in-depth interviews with Christian (n = 17) and Muslim (n = 14) religious leaders in rural Tanzania. Interviews focused on religious leaders' perceptions of hypertension and how they could play a role in promoting blood pressure reduction. We used interpretative phenomenological analysis, a qualitative research method, to understand religious leaders' perspectives on, and experiences with, hypertension. RESULTS: Three main themes emerged during analysis. First, we found that perceptions about causes, treatment, and complications of hypertension are influenced by religious beliefs. Second, religious beliefs can enable engagement with hypertension care through religious texts that support the use of biomedical care. Third, religious leaders are enthusiastic potential partners for promoting hypertension control in their communities. These themes were consistent between religion and gender of the religious leaders. CONCLUSIONS: Religious leaders are eager to learn about hypertension, to share this knowledge with others and to contribute to improved health in their communities.

Caracterización de la hipertensión arterial esencial en adolescentes / Characterization the essential hypertension in adolescents

RESUMEN Fundamento: la hipertensión arterial es causa importante de morbilidad, daño de órganos diana, donde la detección precoz de adolescentes hipertensos asintomáticos es importante como marcador de riesgo de hipertensión futura durante la edad adulta. Objetivo: caracterizar la hipertensión arterial esencial en adolescentes. Métodos: se realizó un estudio analítico longitudinal retrospectivo, en adolescentes ingresados en el Hospital Pediátrico Universitario Dr. Eduardo Agramonte Piña, de la provincia Camagüey procedente de las áreas de salud no diagnosticados por pesquisa sistemática, sino por estar sintomáticos, durante el periodo comprendido desde enero 2017 a enero 2019. El universo quedó constituido por 42 pacientes con diagnóstico de hipertensión arterial esencial. Resultados: el mayor número de hipertensos fue el sexo masculino en ambos grupos de edades, color de piel blanca, los antecedentes familiares de hipertensión arterial, y la obesidad como los factores de riesgo cardiovasculares, la cefalea como la manifestación clínica más frecuente, el tratamiento no farmacológico se recomendó en todos los pacientes, junto al tratamiento farmacológico en la mayoría de los pacientes. Conclusiones: la hipertensión arterial esencial constituye un problema de salud en los adolescentes estudiados, los cuales se asociaron con la presencia de factores de riesgo cardiovasculares. Los antecedentes patológicos familiares de hipertensión arterial y la obesidad fueron los más frecuentes.

ABSTRACT Background: hypertension is an important cause of mobility, damage of target organs, where precocious detection of hypertensive adolescents without symptoms is important as a marker of risk of future hypertension during adult age. Objective: to characterize essential hypertension in adolescents. Methods: a longitudinal retrospective analytic study was carried out in teens affiliated in the University Pediatric Hospital Dr. Eduardo Agramonte Piña, of the province Camagüey, coming from the areas of health diagnosed by systematic investigation, but for being symptomatic, during the period understood from January 2017 to January 2019. El the universe was compound for 42 patients with diagnosis of essential hypertension. Results: the greatest number of hypertensive was the masculine sex in both age groups, white skin, the family record of hypertension, and the obesity as cardiovascular risk factors, headaches as the most frequent clinical manifestation, the non-pharmacologic treatment was recommended in all patients, along with the pharmacologic treatment in the majority of the patients. Conclusions: the essential hypertension constitutes a problem of health in the studied teens, which were associated with the presence of cardiovascular risk factors. The familiar pathological antecedent of hypertension and obesity were the most frequent.

Current challenges for hypertension management: From better hypertension diagnosis to improved patients' adherence and blood pressure control.

Hypertension control still remains a largely unmet challenge for public health systems. Despite the progress in blood pressure (BP) measurement techniques, and the availability of effective and safe antihypertensive drugs, a large number of hypertensive patients are not properly identified, and a significant proportion of those who receive antihypertensive treatment fail to achieve satisfactory control of their BP levels. It is thus not surprising that hypertension is still a major contributor to disease burden and disability worlwide, even in developed countries. This paper will address current challenges in hypertension management and potential strategies for an improvement in this field. In its first part relevant issues related to hypertension diagnosis will be addressed, in particular how to improve identification of sustained BP elevation and specific BP phenotypes such as white coat and masked hypertension trough the combined use of office and out-of-office BP monitoring techniques. In its second part focus will be on how to improve achievement of hypertension control in treated patients by optimization and simplification of medication regimens, including more efficient selection and titration of antihypertensive drugs and their combinations, aimed at achieving a more consistent 24hBP control; and by favoring a more active patients' and physicians' involvement in hypertension management also through BP telemonitoring and mobile health technologies.

Diagnosis of Pediatric Hypertension: European Society of Hypertension-Recommended 24-Hour vs. 24-Hour-Day-Night Ambulatory Blood Pressure Thresholds.

BACKGROUND: The impact of diagnosing pediatric hypertension based on all three-24-hour, day and night ambulatory blood pressure (ABP) thresholds (combined ABP threshold) vs. conventionally used 24-hour ABP threshold is not known. METHODS: In this cross-sectional, retrospective study from a tertiary care outpatient clinic, we evaluated the diagnosis of hypertension based on the 24-hour European Society of Hypertension (ESH) and combined ESH ABP thresholds in untreated children with essential hypertension. The American Academy of Pediatrics (AAP) and Fourth Report thresholds were used to classify office blood pressure (OBP). RESULTS: In 159 children, aged 5-18 years, the 24-hour ESH and combined ESH thresholds classified 82% (95th confidence interval (CI) 0.68, 0.97) ABP similarly with the area under the curve (AUC) of 0.86 (95th CI 0.80, 0.91). However, the AUC of the 2 ABP thresholds was significantly higher in the participants with office hypertension than office normotension, with OBP classified by the AAP (AUC 0.93, 95th CI 0.84, 0.98 vs. 0.80, 95th CI 0.71, 0.88) or Fourth Report (AUC 0.93, 95th CI 0.83, 0.98 vs. 0.81, 95th CI 0.73, 0.88) threshold. With OBP classified by the either OBP threshold, the combined ESH threshold diagnosed significantly more masked hypertension (MH) (difference 15%, 95th CI 4.9, 24.7; P = 0.00); however, the diagnosis of white coat hypertension (WCH) by the 2 ABP thresholds did not differ significantly (difference 4%, 95th CI 1.8, 10; P = 0.16). CONCLUSIONS: In children with essential hypertension, the 24-hour and combined ESH thresholds have a stronger agreement for diagnosing WCH than MH.

Gender differences and determinants of prevalence, awareness, treatment and control of hypertension among adults in China and Sweden.

BACKGROUND: Failure to promote early detection and better management of hypertension will contribute to the increasing burden of cardiovascular diseases. This study aims to assess the gender differences in the prevalence, awareness, treatment and control of hypertension, together with its associated factors, in China and Sweden. METHODS: We used data from two cross-sectional studies: the Västerbotten Intervention Program in northern Sweden (n = 25,511) and the Shanghai survey in eastern China (n = 25,356). We employed multivariable logistic regression to examine the socio-demographics, lifestyle behaviours, and biological factors associated with the prevalence, awareness, treatment and control of hypertension. RESULTS: Men had a higher prevalence of hypertension (43% in Sweden, 39% in China) than their female counterparts (29 and 36%, respectively). In Sweden, men were less aware of, less treated for, and had less control over their hypertension than women. Chinese men were more aware of, had similar levels of treatment for, and had less control over their hypertension compared to women. Awareness and control of hypertension was lower in China compared to Sweden. Only 33 and 38% of hypertensive Chinese men and women who were treated reached the treatment goals, compared with a respective 48 and 59% in Sweden. Old age, impaired glucose tolerance or diabetes, a family history of hypertension or cardiovascular diseases, low physical activity and overweight or obesity were found to increase the odds of hypertension and its diagnosis. CONCLUSIONS: This study shows the age and gender differences in the prevalence, awareness, treatment and control of hypertension among adults in China and Sweden. Multisectoral intervention should be developed to address the increasing burden of sedentary lifestyle, overweight and obesity and diabetes, all of which are linked to the prevention and control of hypertension. Development and implementation of the gender- and context-specific intervention for the prevention and control of hypertension facilitates understanding with regard to the implementation barriers and facilitators.

Guidelines for the Treatment of Pulmonary Arterial Hypertension.

Pulmonary arterial hypertension (PAH) is a rare form of pulmonary hypertension characterized by a progressive obliterative vasculopathy of the distal pulmonary arterial circulation that usually leads to right ventricular failure and death. Over the last 25 years, more than a dozen drugs representing five drug classes have been developed and approved for the treatment of this devastating disease. Due to the small number of patients afflicted by PAH, most health care providers have little experience with its management. To address this gap in medical knowledge, treatment guidelines have been developed by professional organizations and expert committees. Over the last few years, these guidelines have been updated to address findings from recent clinical trials and ongoing experience with these drugs. This review provides an update on the most recently published treatment guidelines for pharmacologic treatment of PAH and incorporates them into a contemporary approach to the treatment of this disease.

Multimodal Photoplethysmography-Based Approaches for Improved Detection of Hypertension.

Elevated blood pressure (BP) is a major cause of death, yet hypertension commonly goes undetected. Owing to its nature, it is typically asymptomatic until later in its progression when the vessel or organ structure has already been compromised. Therefore, noninvasive and continuous BP measurement methods are needed to ensure appropriate diagnosis and early management before hypertension leads to irreversible complications. Photoplethysmography (PPG) is a noninvasive technology with waveform morphologies similar to that of arterial BP waveforms, therefore attracting interest regarding its usability in BP estimation. In recent years, wearable devices incorporating PPG sensors have been proposed to improve the early diagnosis and management of hypertension. Additionally, the need for improved accuracy and convenience has led to the development of devices that incorporate multiple different biosignals with PPG. Through the addition of modalities such as an electrocardiogram, a final measure of the pulse wave velocity is derived, which has been proved to be inversely correlated to BP and to yield accurate estimations. This paper reviews and summarizes recent studies within the period 2010-2019 that combined PPG with other biosignals and offers perspectives on the strengths and weaknesses of current developments to guide future advancements in BP measurement. Our literature review reveals promising measurement accuracies and we comment on the effective combinations of modalities and success of this technology.

Cuffless Single-Site Photoplethysmography for Blood Pressure Monitoring.

One in three adults worldwide has hypertension, which is associated with significant morbidity and mortality. Consequently, there is a global demand for continuous and non-invasive blood pressure (BP) measurements that are convenient, easy to use, and more accurate than the currently available methods for detecting hypertension. This could easily be achieved through the integration of single-site photoplethysmography (PPG) readings into wearable devices, although improved reliability and an understanding of BP estimation accuracy are essential. This review paper focuses on understanding the features of PPG associated with BP and examines the development of this technology over the 2010-2019 period in terms of validation, sample size, diversity of subjects, and datasets used. Challenges and opportunities to move single-site PPG forward are also discussed.

Recommendations for home blood pressure monitoring in Latin American countries: A Latin American Society of Hypertension position paper.

Out-of-office blood pressure (BP) monitoring appears to be a very useful approach to hypertension management insofar it allows to obtain multiple measurements in the usual environment of each individual, allows the detection of hypertension phenotypes, such as white-coat and masked hypertension, and appears to have superior prognostic value than the conventional office BP measurements. Out-of-office BP can be obtained through either home or ambulatory monitoring, which provide complementary and not identical information. Home BP monitoring yields BP values self-measured in subjects' usual living environment; it is an essential method for the evaluation of almost all untreated and treated subjects with suspected or diagnosed hypertension, best if combined with telemonitoring facilities, also allowing long-term monitoring. There is also increasing evidence that home BP monitoring improves long-term hypertension control rates by improving patients' adherence to prescribed treatment. In Latin American Countries, it is widely available, being relatively inexpensive, and well accepted by patients. Current US, Canadian, Japanese, and European guidelines recommend out-of-office BP monitoring to confirm and refine the diagnosis of hypertension.

Ambulatory blood pressure monitoring over 24 h: A Latin American Society of Hypertension position paper-accessibility, clinical use and cost effectiveness of ABPM in Latin America in year 2020.

Accurate office blood pressure measurement remains crucial in the diagnosis and management of hypertension worldwide, including Latin America (LA). Office blood pressure (OBP) measurement is still the leading technique in LA for screening and diagnosis of hypertension, monitoring of treatment, and long-term follow-up. Despite this, due to the increasing awareness of the limitations affecting OBP and to the accumulating evidence on the importance of ambulatory BP monitoring (ABPM), as a complement of OBP in the clinical approach to the hypertensive patient, a progressively greater attention has been paid worldwide to the information on daytime and nighttime BP patterns offered by 24-h ABPM in the diagnostic, prognostic, and therapeutic management of hypertension. In LA countries, most of the Scientific Societies of Hypertension and/or Cardiology have issued guidelines for hypertension care, and most of them include a special section on ABPM. Also, full guidelines on ABPM are available. However, despite the available evidence on the advantages of ABPM for the diagnosis and management of hypertension in LA, availability of ABPM is often restricted to cities with large population, and access to this technology by lower-income patients is sometimes limited by its excessive cost. The authors hope that this document might stimulate health authorities in each LA Country, as well as in other countries in the world, to regulate ABPM access and to widen the range of patients able to access the benefits of this technique.