The optimal use of automated office blood pressure measurement in clinical practice

This evidence‐based article endorses the use of automated office blood pressure (AOBP). AOBP is the most favorable office blood pressure (BP) measuring technique as it provides accurate readings with 3‐15 mm Hg lower values than the casual conventional office measurements with auscultatory or semi‐automated oscillometric devices and relates closely to awake ABP readings. The AOBP technique seems to be superior to conventional office BP in predicting hypertension‐mediated organ damage and appears to be equally reliable to awake ABP in the prediction of cardiovascular (CV) disease. AOBP readings should be obtained either unattended, with the patient alone in the examination room, or attended with the presence of personnel in the room but with no talking to the patient, although this recommendation is not frequently followed in routine clinical practice. To optimize office BP readings, the type of device, the rest period before AOBP measurements (preceding rest), and the time intervals between measurements were evaluated. As AOBP readings have the advantage of removing many confounding factors, the authors propose to perform measurements with a preceding rest in all patients at the initial visit; if AOBP readings remain <130 mm Hg in subsequent visits, measurements could be accepted, otherwise, if are higher, patients should be evaluated by out‐of‐office BP measurements.     

Automated office blood pressure is in agreement with awake and mean 24‐hour ambulatory blood pressure at the lower blood pressure range

Automated office blood pressure measurement eliminates the white coat effect and is associated with awake ambulatory blood pressure. This study examined whether automated office blood pressure values at lower limits were comparable to those of awake and mean 24‐hour ambulatory blood pressure. A total of 552 patients were included in the study, involving 293 (53.1%) men and 259 (46.9%) women, with a mean age 55.0 ± 12.5, of whom 36% were treated for hypertension. Both systolic and diastolic automated office blood pressures exhibited lower values compared to awake ambulatory blood pressure among 254 individuals with systolic automated office blood pressure <130 mm Hg (119 ± 8 mm Hg vs 125 ± 11 mm Hg, P < .0001 and 75 ± 9 mm Hg vs 79 ± 9 mm Hg, P < .0001 for systolic and diastolic BPs, respectively). Furthermore, the comparison of systolic automated office blood pressure to the mean 24‐hour ambulatory blood pressure levels also showed lower values (119 ± 8 vs 121 ± 10, P = .007), whereas the diastolic automated office blood pressure measurements were similar to 24‐hour ambulatory blood pressure values. Our findings show that when automated office blood pressure readings express values <130/80 mm Hg in repeated office visits, further investigation should be performed only when masked hypertension is suspected; otherwise, higher automated office blood pressure values could be used for the diagnosis of uncontrolled hypertension, especially in individuals with organ damage.     

Antecedent rest may not be necessary for automated office blood pressure at lower treatment targets

In SPRINT (Systolic Blood Pressure Intervention Trial), use of the Omron 907XL blood pressure (BP) monitor set at 5 minutes of antecedent rest to record BP produced an automated office BP value 7/6 mm Hg lower than awake ambulatory BP at 27 months. The authors studied the impact on automated office BP of setting the Omron 907XL to 0 minutes instead of 5 minutes of rest in patients with readings in the lower normal BP range, similar to on‐treatment BP in the SPRINT intensive therapy group. Patients (n = 100) in cardiac rehabilitation were randomized to three BP readings at 1‐minute intervals using an Omron 907XL BP device set for 5 or 0 minutes of antecedent rest. Mean (±standard deviation) automated office BP (mm Hg) after 5 minutes of rest (120.2 ± 14.6/66.9 ± 8.6 mm Hg) was lower (P < .001/P < .01) than without rest (124.2 ± 16.4/67.9 ± 9.1 mm Hg). When target BP is in the lower normal range, automated office BP recorded without antecedent rest using an Omron 907XL device should be higher and closer to the awake ambulatory BP, compared with readings taken after 5 minutes of rest.     

The first study comparing a wearable watch‐type blood pressure monitor with a conventional ambulatory blood pressure monitor on in‐office and out‐of‐office settings

Wearable blood pressure (BP) monitoring devices which measure BP levels accurately both in and out of the office are valuable for hypertension management using digital technology. The authors have conducted the first comparison study of BPs measured by a recently developed wrist‐worn watch‐type oscillometric BP monitoring (WBPM) device, the “HeartGuide,” versus BPs measured by an ambulatory BP monitoring (ABPM) device, A&D TM‐2441, in the office (total of 4 readings alternately measured in the sitting position) and outside the office (30‐minutes interval measurements during daytime) in 50 consecutive patients (mean age 66.1 ± 10.8 years). The 2 BP monitoring devices were simultaneously worn on the same non‐dominant arm throughout the monitoring period. The mean difference (±SD) in systolic BPs (average of 2 readings) between WBPM and ABPM was 0.8 ± 12.8 mm Hg (P = .564) in the office and 3.2 ± 17.0 mm Hg (P < .001) outside the office. The proportion of differences that were within ±10 mm Hg was 58.7% in the office and 47.2% outside the office. In a mixed‐effects model analysis, the temporal trend in the difference between the out‐of‐office BPs measured by the two devices was not statistically significant. In conclusion, the difference between the WBPM and ABPM device was acceptable both in and out of the office.     

Comparison of awake ambulatory blood pressure and automated office blood pressure using linear regression analysis in untreated patients in routine clinical practice

The recent American hypertension guidelines recommended a threshold of 130/80 mmHg to define hypertension on the basis of office, home or ambulatory blood pressure (BP). Despite recognizing the potential advantages of automated office (AO)BP, the recommendations only considered conventional office BP, without providing supporting evidence and without taking into account the well documented difference between office BP recorded in research studies versus routine clinical practice, the latter being about 10/7 mmHg higher. Accordingly, we examined the relationship between AOBP and awake ambulatory BP, which the guidelines considered to be a better predictor of future cardiovascular risk than office BP. AOBP readings and 24‐hour ambulatory BP recordings were obtained in 514 untreated patients referred for ambulatory BP monitoring in routine clinical practice. The relationship between mean AOBP and mean awake ambulatory BP was examined using linear regression analysis with and without adjustment for age and sex. Special attention was given to the thresholds of 130/80 and 135/85 mmHg, the latter value being the recognized threshold for defining hypertension using awake ambulatory BP, home BP and AOBP in other guidelines. The mean adjusted AOBP of 130/80 and 135/85 mmHg corresponded to mean awake ambulatory BP values of 132.1/81.5 and 134.4/84.6 mmHg, respectively. These findings support the use of AOBP as the method of choice for determining office BP in routine clinical practice, regardless of which of the two thresholds are used for diagnosing hypertension, with an AOBP of 135/85 mmHg being somewhat closer to the corresponding value for awake ambulatory BP.     

Regression to the mean in home blood pressure: Analyses of the BP GUIDE study

The aim of our study was to estimate the size of regression to the mean with home blood pressure (BP) monitoring and compare with that for office BP. Office and home BP measures were obtained from the BP GUIDE (value of central Blood Pressure for GUIDing managEment for hypertension) study, in which 286 patients had BP measured every 3 months for 12 months. Patients were categorized by 10 mm Hg strata of baseline BP, and regression to the mean measures was calculated for home and office BP. High baseline home BP readings tended to be lower on long‐term follow‐up, and low baseline readings tended to be higher. For example, patients in the group with mean baseline home systolic BP ≥ 150 mm Hg had a mean baseline systolic BP of 156 mm Hg, which fell to 143 mm Hg at 12 months; and patients in the group with mean baseline home systolic BP < 120 mm Hg had a mean baseline systolic BP of 113 mm Hg which rose to 120 mm Hg at 12 months. Similar patterns were seen in intervention and control groups, and for diastolic BP. The regression dilution ratio for home systolic BP and diastolic BP was 0.52 and 0.64, respectively, compared to 0.40 and 0.55 for office systolic BP and diastolic BP, respectively. Home BP is subject to regression to the mean to a similar degree as office BP. These findings have implications for the diagnosis and management of hypertension using home BP.     

急性脑卒中患者血压特点的分析

目的研究急性脑卒中患者血压影响因素及动态血压特点。方法82例发病在7天内的急性脑卒中患者。记录患者住院诊室血压及24 h动态血压。血压≥140/90 mm Hg(1 mm Hg=0.133 kPa)为诊室血压升高;24 h动态血压平均值≥130/80 mm Hg、日间平均值≥135/85 mm Hg、夜间平均值≥125/75 mm Hg为动态血压升高。结果既往高血压病史对急性脑卒中患者诊室血压升高有影响(P<0.05)。有高血压病史者平均诊室血压(146.02±18.89)/(86.36±11.52)mm Hg,无高血压病史者平均诊室血压(136.22±14.63)/(82.61±11.86)mm Hg,二者收缩压水平差异有显著性意义(P<0.05)。急性脑卒中患者动态血压表现为夜间血压负荷增加,24 h平均血压于发病后4~5天明显升高,6~7天降低。诊室血压升高与诊室血压正常比较,血压形态均以非杓形和反杓形为主,2组差异无显著性意义(P>0.05)。结论急性脑卒中诊室血压升高与高血压病史有关,急性脑卒中随发病时间延长,血压呈下降趋势。     

High prevalence of masked uncontrolled morning hypertension in elderly non‐valvular atrial fibrillation patients: Home blood pressure substudy of the ANAFIE Registry

In the ANAFIE Registry home blood pressure subcohort, we evaluated 5204 patients aged ≥75 years with non‐valvular atrial fibrillation (NVAF) to assess blood pressure (BP) control, prevalence of masked hypertension, and anticoagulant use. Mean clinic (C) and home (H) systolic/diastolic BP(SBP/DBP) was 128.5/71.3 and 127.7/72.6 mm Hg, respectively. Overall, 77.5% of patients had hypertension; of these, 27.7%, 13.4%, 23.4%, and 35.6% had well‐controlled, white coat, masked, and sustained hypertension, respectively. Masked hypertension prevalence increased with diabetes, decreased renal function, age ≥80 years, current smoker status, and chronic obstructive pulmonary disease. By morning/evening average, 59.0% of patients had mean H‐SBP ≥ 125 mm Hg; 48.9% had mean C‐SBP ≥ 130 mm Hg. Early morning hypertension (morning H‐SBP ≥ 125 mm Hg) was found in 65.9% of patients. Although 51.1% of patients had well‐controlled C‐SBP, 52.5% of these had uncontrolled morning H‐SBP. In elderly NVAF patients, morning H‐BP was poorly controlled, and masked uncontrolled morning hypertension remains significant.     

Comparison of manual and automated auscultatory blood pressure during graded exercise among people with type 2 diabetes

Manual measurement of blood pressure (BP) during exercise testing is the recommended standard. Automated measurement of BP is an alternative method used during clinical exercise testing, but there is little data comparing manual and automated BP in this setting. The aim of this study was to determine the concordance between manual and automated BP during a standard clinical treadmill exercise test. 416 participants (66 ± 5 years; 54% male) completed a Bruce treadmill exercise test at baseline or follow‐up within a clinical trial of participants with type 2 diabetes mellitus. Manual and automated BP were measured simultaneously at each exercise test stage. Manual BP was measured by a technician blinded to automated BP values (Tango+, Suntech). Concordance between manual and automated BP was assessed using mean differences and intraclass correlations (ICC). Concordance between manual and automated BP across all exercise stages was excellent for systolic BP (overall mean difference: 3 ± 11 mm Hg, P = .598; ICC = 0.964 [95% CI 0.942‐0.977] and pulse pressure (overall mean difference: 2 ± 14 mm Hg, P = .595; ICC = 0.934 [95% CI 0.899‐0.956]). Concordance between manual and automated diastolic BP across all exercise stages was moderate‐to‐good (overall mean difference: 1 ± 9 mm Hg, P = .905; ICC = 0.784 [95% CI 0.672‐0.858]). Automated BP using the Tango + device is concordant with manual BP during early stages of a standard clinical exercise test. Thus, this automated method may be a suitable alternative to manual measurement of BP during clinical exercise testing.     

Comparison between unattended automated office blood pressure and conventional office blood pressure under the environment of health checkup among Japanese general population

Unattended automated office blood pressure (AOBP) measurement has been endorsed as the preferred in‐office measurement modality in recent Canadian and American clinical practice guidelines. However, the difference between AOBP and conventional office blood pressure (CBP) under the environment of a health checkup remains unclear. We aimed to identify the clinical significance of AOBP as compared to CBP under the environment of a health checkup. There were 491 participants (333 females, mean age of 62.5 years) who were at least 20 years old, including 179 participants who were previously diagnosed with hypertension. Mean AOBPs were 131.8 ± 20.9/76.6 ± 11.7 mm Hg, and CBPs were 135.6 ± 21.6/77.3 ± 11.5 mm Hg. There was a difference of 3.9 mm Hg in systolic blood pressure (SBP) and 0.8 mm Hg in diastolic BP between AOBP and CBP. In all participants, SBP and pulse pressure, as well as the white coat effect (WCE), increased with age. The cutoff value used was 140/90 mm Hg for CBP and 135/85 mm Hg for AOBP, and the prevalence of WCE and masked hypertension effect (MHE) was 12.4% and 14.1%, respectively. Even in a health checkup environment of the general population, there was a difference between the AOBP and CBP, and the WCE was observed more strongly in the elderly with a history of hypertension, suggesting that a combination of AOBP with CBP may be useful in detecting WCE and MHE in all clinical scenarios including health checkups, and help solve the “hypertension paradox” not only in Japan but in all over the world.     

Comparison of day‐to‐day blood pressure variability in hypertensive patients with type 2 diabetes mellitus to those without diabetes: Asia BP@Home Study

Blood pressure variability (BPV) has been shown to be independently associated with cardiovascular (CV) mortality and morbidity. Patients with type 2 diabetes mellitus (T2DM) have also been shown to have increased BPV. We aimed to compare BPV in hypertensive patients with diabetes with those without diabetes. A total of 1443 hypertensive patients measured their blood pressure (BP) twice in the morning and twice before bed at home for a week. Demographic data, history of T2DM, and anti‐hypertensive use were captured. Clinic BP was measured twice in the clinic. Control of BP was defined as clinic systolic BP (SBP) <140 mm Hg and home SBP < 135 mm Hg. BPV was based on home SBP measurements. A total of 362(25.1%) hypertensives had diabetes and 47.4% were male. Mean age was 62.3 ± 12.1 years. There was no difference in the mean clinic SBP in both groups (139.9 mm Hg vs 138.4 mm Hg P = .188). However, the mean morning home SBP was significantly higher and control rate lower in hypertensives with diabetes than those without (132.3 ± 15 mm Hg vs 129.7 ± 14.4 mm Hg P = .005, 39.4% vs 47.6% P = .007), respectively. Masked uncontrolled morning hypertension was higher in those with diabetes versus those without (12.8% vs 8.4%, respectively). There was no statistically significant difference in BPV between those with and without diabetes. In summary, clinic SBP was similar in hypertensives with or without diabetes. However, control of BP based on both clinic and home SBP thresholds was poorer in hypertensives with diabetes compared to those without. Masked uncontrolled morning hypertension was higher in those with diabetes than those without. There was no difference in BPV between the two groups.     

Reproducibility of blood pressure dipping: Relation to day-to-day variability in sleep quality

Previous studies of the reproducibility of blood pressure (BP) dipping have yielded inconsistent results. Few have examined factors that may influence day-to-day differences in dipping. Ambulatory BP monitoring was performed on three occasions, approximately 1 week apart, in 115 untreated adult subjects with elevated clinic BPs. The mean ± standard deviation BP dip was 18 ± 7/15 ± 5 mm Hg (sleep/awake BP ratio = 0.87 ± 0.05/0.82 ± 0.06), with a median (interquartile range) day-to-day variation of 5.2 (3.1–8.1)/4.3 (2.8–5.6) mm Hg. There was no decrease in variability with successive measurements. The reproducibility coefficient (5.6 [95% confidence interval, 5.1–6.1] mm Hg) was greater and the intraclass correlation coefficient (0.53 [95% confidence interval, 0.42–0.63]) was smaller for the systolic dip than for 24-hour or awake systolic BPs, suggesting greater day-to-day variability in dipping. Variability in systolic dipping was greater in subjects with higher awake BP, but was not related to age, gender, race, or body mass index. Within individuals, day-to-day variations in dipping were related to variations in the fragmentation index (P < .001), a measure of sleep quality. Although mean 24-hour and awake BPs were relatively stable over repeated monitoring days, our study confirms substantial variability in BP dipping. Day-to-day differences in dipping are related to sleep quality.     

Ten‐year changes in ambulatory blood pressure: The prognostic value of ambulatory pulse pressure

Blood pressure (BP) changes and risk factors associated with pulse pressure (PP) increase in elderly people have rarely been studied using ambulatory blood pressure monitoring (ABPM). The aim is to evaluate 10‐year ambulatory blood pressure (ABP) changes in older hypertensives, focusing on PP and its associations with mortality. An observational study was conducted on 119 consecutive older treated hypertensives evaluated at baseline (T0) and after 10 years (T1). Treatment adherence was carefully assessed. The authors considered clinical parameters at T1 only in survivors (n = 87). Patients with controlled ABP both at T0 and T1 were considered as having sustained BP control. Change in 24‐hour PP between T0 and T1 (Δ24‐hour PP) was considered for the analyses. Mean age at T0: 69.4 ± 3.7 years. Females: 57.5%. Significant decrease in 24‐hour, daytime, and nighttime diastolic BP (all P < .05) coupled with an increase in 24‐hour, daytime, and nighttime PP (all P < .05) were observed at T1. Sustained daytime BP control was associated with lower 24‐hour PP increase than nonsustained daytime BP control (+2.23 ± 9.36 vs +7.79 ± 8.64 mm Hg; P = .037). The association between sustained daytime BP control and Δ24‐hour PP remained significant even after adjusting for age, sex, and 24‐hour PP at T0 (β=0.39; P = .035). Both 24‐hour systolic BP and 24‐hour PP at T0 predicted mortality (adjusted HR 1.07, P = .001; adjusted HR 1.25, P < .001, respectively). After ROC comparison (P = .001), 24‐hour PP better predicted mortality than 24‐hour systolic BP. The data confirm how ABP control affects vascular aging leading to PP increase. Both ambulatory PP and systolic BP rather than diastolic BP predict mortality in older treated hypertensives.     

Nocturnal blood pressure patterns and cardiovascular outcomes in patients with masked hypertension

Masked hypertension (MHT) is characterized by normal clinic and above normal 24‐hour ambulatory blood pressure (BP) levels. We evaluated clinical characteristics and CV outcomes of different nocturnal patterns of MHT. We analyzed data derived from a large cohort of adult individuals, who consecutively underwent home, clinic, and ambulatory BP monitoring at our Hypertension Unit between January 2007 and December 2016. MHT was defined as clinic BP <140/90 mm Hg and 24‐hour BP ≥ 130/80 mm Hg, and stratified into three groups according to dipping status: (a) dippers, (b) nondippers, and (c) reverse dippers. From an overall sample of 6695 individuals, we selected 2628 (46.2%) adult untreated individuals, among whom 153 (5.0%) had MHT. In this group, 67 (43.8%) were nondippers, 65 (42.5%) dippers, and 21 (13.7%) reverse dippers. No significant differences were found among groups regarding demographics, clinical characteristics, and prevalence of risk factors, excluding older age in reverse dippers compared to other groups (P < 0.001). Systolic BP levels were significantly higher in reverse dippers than in other groups at both 24‐hour (135.6 ± 8.5 vs 130.4 ± 6.0 vs 128.2 ± 6.8 mm Hg, respectively; P < 0.001) and nighttime periods (138.2 ± 9.1 vs 125.0 ± 6.3 vs 114.5 ± 7.7 mm Hg; P < 0.001). Reverse dipping was associated with a significantly higher risk of stroke, even after correction for age, gender, BMI, dyslipidemia, and diabetes (OR 18.660; 95% IC [1.056‐33.813]; P = 0.046). MHT with reverse dipping status was associated with higher burden of BP and relatively high risk of stroke compared to both dipping and nondipping profiles, although a limited number of CV outcomes have been recorded during the follow‐up.     

The association between ambulatory systolic blood pressure and cardiovascular events in a selected population with intensive control of cardiovascular risk factors

Recent guidelines recommend a target clinic systolic blood pressure (BP) of <140 mm Hg. These recommendations are based on the relationship of office BP measurements and cardiovascular (CV) events. We evaluated the association between 24-hour ambulatory BP measurements (24H ABPM) and CV events in a selected population with intensive control of CV risk factors. We retrospectively followed all patients who had undergone 24H ABPM during 2005 at the Institute of Periodic Medical Examinations, Chaim Sheba Medical Center, Tel-Hashomer, Israel, to monitor the development of CV events. These patients were followed closely and treated meticulously in order to control CV risk factors. The study population consisted of 317 patients (81% males; mean age, 59.2 ± 9.8 years) followed for a mean period of 6.4 ± 2.1 years (median, 6 years). During follow-up, 22 patients had their first CV event. Patients who experienced CV events were significantly older, more likely diabetic, and had a history of previous CV disease. Twenty-four-hour ABPM systolic BP ≥140 mm Hg was not associated with increased CV events, whereas 24H ABPM systolic BP ≥150 mm Hg was. Logistic regression analysis showed that 24H ABPM systolic BP ≥150 mm Hg, a former smoker, old age, and a history of CV disease were associated with CV events during follow-up. We found that, in a population aggressively managed for CV risk factors, 24H ABPM systolic BP ≥150 mm Hg is associated with increased CV events.     

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.     

A randomized controlled trial on the blood pressure–lowering effect of amlodipine and nifedipine‐GITS in sustained hypertension

In a multicenter, randomized trial, we investigated whether the long half‐time dihydropyridine calcium channel blocker amlodipine was more efficacious than the gastrointestinal therapeutic system (GITS) formulation of nifedipine in lowering ambulatory blood pressure (BP) in sustained hypertension (clinic systolic/diastolic BP 140‐179/90‐109 mm Hg and 24‐hour systolic/diastolic BP ≥ 130/80 mm Hg). Eligible patients were randomly assigned to amlodipine 5‐10 mg/day or nifedipine‐GITS 30‐60 mg/day. Ambulatory BP monitoring was performed for 24 hours at baseline and 4‐week treatment and for 48 hours at 8‐week treatment with a dose of medication missed on the second day. After 8‐week treatment, BP was similarly reduced in the amlodipine (n = 257) and nifedipine‐GITS groups (n = 248) for both clinic and ambulatory (24‐hour systolic/diastolic BP 10.3/6.5 vs 10.9/6.3 mm Hg, P ≥ 0.24) measurements. However, after missing a dose of medication, ambulatory BP reductions were greater in the amlodipine than nifedipine‐GITS group, with a significant (P ≤ 0.04) between‐group difference in 24‐hour (–1.2 mm Hg) and daytime diastolic BP (–1.5 mm Hg). In conclusion, amlodipine and nifedipine‐GITS were efficacious in reducing 24‐hour BP. When a dose of medication was missed, amlodipine became more efficacious than nifedipine‐GITS.     

Unattended automated office blood pressure measurement: Time efficiency and barriers to implementation/utilization

Unattended automated office blood pressure (BP) measurement (u‐AOBP) improves office BP measurement accuracy and reduces white‐coat BP elevation, but there are reservations about its time efficiency in primary care. We used time‐stamp methodology to measure u‐AOBP procedure times performed without a rest period in 130 patients during routine clinic visits to three primary care clinics with 2.5‐4.9 years u‐AOBP experience. We documented the clinical activities of 30 medical assistants during the u‐AOBP procedures. We also assessed MA and clinician satisfaction and knowledge about u‐AOBP performance and interpretation. Median u‐AOBP procedure time was <5 minutes, and MAs engaged in productive clinical activities during 83% of the procedures. Ninety‐three percent of MAs and 100% of clinicians in the clinics agreed that u‐AOBP is an efficient method to improve hypertension management. Barriers to effective u‐AOBP implementation and ongoing utilization included initial difficulty incorporating u‐AOBP into clinic workflow and medical staff knowledge deficiencies concerning correct u‐AOBP performance and interpretation despite prior training and experience with the procedure. Intensive u‐AOBP education and training programs are needed to facilitate effective u‐AOBP implementation into primary care. The time required to perform u‐AOBP can be utilized productively by staff.     

Exaggerated blood pressure variability is associated with memory impairment in very elderly patients

We investigated the association between working memory (WM) impairment and blood pressure variability (BPV) in very elderly patients. Japanese outpatients ≥80 years who engaged in normal activities of daily living were the study cohort. WM function was evaluated by a simple visual WM test consisting of 3 figures. We considered the number of figures recalled by the patient his/her test score. We defined the patients with a score of 0 or 1 as those with WM impairment and those with scores of 2 or 3 as those without. To investigate the relative risk of WM impairment, we evaluated each patient's 24 hour ambulatory systolic blood pressure (SBP) and its weighted standard deviation (SD_SBP), office SBP, and the visit‐to‐visit SD_SBP during the 1 year period from the patient's enrollment. A total of 66 patients (mean 84 ± 3.6 years) showed WM impairment, and 431 patients (mean 83 ± 3.1 years) showed no WM impairment. There were no significant differences in 24 hour ambulatory SBP or office SBP between these two groups. However, the WM impairment patients showed significantly higher weighted SD_SBP and visit‐to‐visit SD_SBP values compared to the no‐impairment group even after adjusting for age. Among these ≥80‐year‐old patients, those with the highest quartile of both weighted SD_SBP (≥21.4 mm Hg) and visit‐to‐visit SD_SBP (≥14.5 mm Hg) showed the highest relative risk (odds ratio 3.52, 95% confidence interval 1.42‐8.72) for WM impairment. Exaggerated blood pressure variability parameters were significantly associated with working memory impairment in very elderly individuals.     

Validation of a wrist‐type home nocturnal blood pressure monitor in the sitting and supine position according to the ANSI/AAMI/ISO81060‐2:2013 guidelines: Omron HEM‐9600T

The purpose of the present study was to evaluate the performance of the Omron HEM‐9600T, an automatic wrist‐type device for self BP measurement, in the sitting position with the wrist at heart level and supine position according to the ANSI/AAMI/ISO81060‐2:2013 guidelines. In the supine position, we evaluated the device under 3 different conditions: using the supine with sideways palm position, the supine with upwards palm position, and the supine with downwards palm position. After 106 subjects were screened and 21 subjects were excluded, the same 85 subjects (38 men [44.7%] and 47 women [55.3%]) were included in the analyses for each position. The average age of the subjects was 54.5 ± 12.2 years (mean ± SD). The mean wrist circumference was 17.0 ± 2.4 cm. The wrist size distribution fulfilled the requirements of the guidelines. The mean differences between reference BPs and HEM‐9600T readings were 1.0 ± 6.7/1.4 ± 5.7 mm Hg, 6.6 ± 7.2/5.5 ± 6.0 mm Hg, 4.8 ± 7.2/4.9 ± 5.8 mm Hg, and 2.1 ± 7.2/2.8 ± 6.8 mm Hg for SBP/DBP in the sitting position, supine with sideways palm position, supine with upwards palm position, and supine with downwards palm position, respectively. In conclusion, the Omron HEM‐9600T in the sitting position fulfilled the validation criteria of the ANSI/AAMI/ISO81060‐2:2013 guidelines. On the other hand, the accuracies of HEM‐9600T in the supine position differed depending on the positioning of the palm, with only the downwards palm‐position measurement fulfilling both validation criteria of the ANSI/AAMI/ISO81060‐2:2013 guidelines.