Adherence to antihypertensive treatment: a critical factor for blood pressure control.

BACKGROUND: To compare rates of blood pressure (BP) control with the level of adherence to antihypertensive treatment and factors influencing compliance in Greek patients. DESIGN: An observational cross-sectional study on 1000 consecutively treated hypertensive patients, admitted to a University department of general surgery in a Greek hospital. METHODS: Patients were interviewed by the same doctor using pre-coded questionnaires with questions on demographic data, health and treatment status. Blood pressure was measured using a standard mercury sphygmomanometer. Treatment of hypertension was defined as current use of antihypertensive medication. Compliance was defined as an affirmative reply to a number of questions regarding regular use of antihypertensive medication according to the physician's instructions. RESULTS: Satisfactory BP control (levels <140/90 mmHg) was documented in only 20% of the treated hypertensives. Compliance to antihypertensive treatment was found in only 15% of the patients. Control of BP was positively associated with compliance. Compliance was more common among patients aged <60, city dwellers, the better educated, those more adequately counselled by their physicians and those followed by a private doctor. As regards treatment, compliance was better among those taking one antihypertensive tablet per day, those who had never changed their antihypertensive regimen and those who had never changed their doctor. CONCLUSIONS: Compliance is associated with more effective BP control. Physicians can enhance patient compliance and hypertension control by devoting more time to counselling, avoiding unnecessary changes in drug regimens and restricting the tablet numbers.     

Self-monitoring of blood pressure should be used in clinical trials

The number of studies of the efficacy of drugs in hypertension and of their effects on morbidity and mortality continues to be large. Traditionally such studies were carried out by measuring the blood pressure (BP) in the office. Recently, there has been an increasing use of other approaches, such as self-measurement. The advantages of this technique may be the achievement of greater precision of measurement, explained by elimination of the white-coat effect, reduction in placebo effect and reduction in variability of BP. Some have even noted a greater reproducibility than using ambulatory BP monitoring. We now have available reference values and normal ranges for self-BP monitoring. The feasibility and the limitations of self-BP measurement are also known. Self-measurement allows multiple recordings of BP over the short term as well as over the long term. Moreover, the compliance of this technique is satisfying. The analysis of the data requires precise recommendations. One cannot refer to trough : peak ratio, which is used in ambulatory recordings. However, other methods of analysis such as evening BP : morning BP ratio or measures taken after taking treatment are useful. The number of subjects needed for a study is much smaller than in a study performed using office measurements for a similar or better statistical power. Such a method has a higher predictive value than clinic measurement both for study of end organ damage and for morbidity and mortality. Finally home measurement is much less costly. In conclusion, provided one uses validated equipment and if one follows recommendations for each measurement and for the succession of measurements, then self-measurement of BP at home seems a useful and practical tool for therapeutic trials.     

Uneven Accuracy of Home Blood Pressure Measurement: A Multicentric Survey

Home blood pressure monitoring (HBPM) is increasingly commonly performed, but the concordance between patient HBPM measurement technique and prevailing recommendations has not been well‐assessed according to the literature. The authors performed a multicentric survey to evaluate the degree of patients' adherence to current recommendations on HBPM, and investigate potential predictors of a higher‐quality self‐measurement. A structured questionnaire was administered to 725 Italian outpatient hypertensive patients (mean age, 52.2±14.4 years). Overall, ≥10 recommended procedures were followed by 52.8% of the participants; only 1.0% followed all recommendations. A total of 49.7% of participants rested for ≥5 minutes before the measurement, 36.8% recorded BP more than once in each measurement session, and 34.3% used a chair or bed saddle to support their back. Less than 40% of the patients received some form of training by health professionals. After multivariate analysis, patients receiving/reading instructions showed higher‐quality HBPM (P<.01). The accuracy of HBPM needs to be improved, and more efforts should be devoted to provide patient training on HBPM, especially on the less‐frequently followed recommendations.     

What is the value of home blood pressure measurement in patients with mild hypertension?

To investigate the value of home blood pressure (BP) measurements, the BP was recorded daily by the patient at home and compared with recordings in the physician's office and with a 24-hour BP recording taken with a noninvasive ambulatory BP recorder in a group of 93 patients with mild untreated hypertension. Office BPs (mean 148/94 mm Hg) were higher than either home (138/89 mm Hg) or average 24-hour BPs (131/89 mm Hg). For systolic BP, home and office measurements gave similar correlations with 24-hour BP (0.67 and 0.55). For diastolic BP, however, home readings were lower and more accurate (0.76 vs 0.36). Thus, our findings indicate that home readings reflect the overall level of BP more reliably than office readings, and if due consideration is given to the fact that they are usually lower than office readings, they may be used as an alternative and cost-effective means of evaluating patients with mild hypertension.     

The 2005 Canadian Hypertension Education Program recommendations for the management of hypertension: part 1- blood pressure measurement, diagnosis and assessment of risk

OBJECTIVE: To provide updated, evidence-based recommendations for the diagnosis and assessment of adults with high blood pressure (BP). OPTIONS AND OUTCOMES: For persons in whom a high BP value is recorded, the assignment of a diagnosis of hypertension is dependent on the appropriate measurement of BP, the level of the BP elevation and the duration of follow-up. In addition, the presence of cardiovascular risk factors and target organ damage should be assessed to determine the urgency, intensity and type of treatment. For persons diagnosed as having hypertension, estimating overall risk of adverse cardiovascular outcomes requires an assessment of other vascular risk factors and hypertensive target organ damage. EVIDENCE: MEDLINE searches were conducted from November 2003 to October 2004 to update the 2004 recommendations. Reference lists were scanned, experts were polled, and the personal files of the authors and subgroup members were used to identify other studies. Identified articles were reviewed and appraised using prespecified levels of evidence by content and methodological experts. As per previous years, only studies that had been published in the peer-reviewed literature were included; evidence from abstracts, conference presentations and unpublished personal communications was not included. RECOMMENDATIONS: This document contains recommendations for BP measurement, diagnosis of hypertension and assessment of cardiovascular risk for adults with high BP. These include the accurate measurement of BP, criteria for diagnosis of hypertension, and recommendations for follow-up, assessment of overall cardiovascular risk, routine and optional laboratory testing, assessment for renovascular and endocrine causes, home and ambulatory BP monitoring, and the role of echocardiography for those with hypertension. Key features of the 2005 recommendations include an expedited diagnostic algorithm for hypertension and an endorsement of the use of home/self and ambulatory BP assessment as validated techniques in establishing the diagnosis of hypertension. VALIDATION: All recommendations were graded according to the strength of the evidence and voted on by the 43 members of the Canadian Hypertension Education Program Evidence-Based Recommendations Task Force. All recommendations reported in the present paper received at least 95% consensus. These guidelines will continue to be updated annually.     

Blood pressure surge on rising

OBJECTIVES: Since cardiovascular complications tend to occur more often in the morning, it is tempting to link this to the surge in blood pressure (BP) on rising. Our objective was to measure BP and heart rate (HR) on rising and compare values with those recorded immediately beforehand and seek variables related to marked changes in the two parameters in a cohort of initially untreated hypertensives. METHODS: The 24-h ambulatory BP measurement along with an accurate measurement of the BP on rising (either manually or automatically from the device coupled with a position sensor) was obtained in untreated hypertensives. Left ventricular mass was measured with echocardiography at baseline. Patients were then treated and followed by their general physician and news was obtained at regular intervals. RESULTS: A total of 507 patients with adequate recordings were included. Rising led to a mean increase of 14 mmHg in systolic blood pressure (SBP) and a 13 beats per minute (bpm) increase in HR. This elevation in BP on rising in the morning differed from the alteration in BP on normal changes in position. It was associated with left ventricular hypertrophy at baseline and an increased risk of future cardiovascular complications. CONCLUSIONS: Our study confirms the surge in BP on rising in the morning. This elevation in BP is accompanied by an acceleration in cardiac rhythm with no significant correlation between the two parameters. The increase in BP on rising was linked with the overall variability in BP, but was independent of the mean BP over 24 h. It was associated with an increased risk of cardiovascular complications independently of age and average 24-h SBP.     

A review of blood pressure measurement protocols among hypertension trials: implications for “evidence-based” clinical practice

Hypertension guidelines recommend following published standardized protocols to obtain accurate blood pressure (BP) readings in clinical practice. However, the various measurement techniques among clinical trials that provide the basis for evidence-based management have not been evaluated or compared with guideline recommendations. We reviewed published information regarding BP measurement in clinical trials (n = 64) from 1990–2014 by searching PubMed and Google Scholar databases. Every trial failed to provide published information regarding at least one of the 10 methodological aspects we evaluated. Details regarding the health-care provider(s) performing measurement(s), temporal-relation to last medication dosage, number of readings, resting time before (and between recordings), and the device(s) used varied among the trials and often differed from clinical recommendations. Most studies did evaluate ≥2 BP readings in a seated position, presumably from the upper arm (although explicit acknowledgment of this latter detail was rare). When indicated, “trough” BP levels were most commonly obtained (15 of 16 trials), whereas the usage of automated devices increased over time. Numerous aspects of BP measurement varied considerably across trials and often from most recent guideline recommendations. The lack of uniform methodologies in outcome studies that form the foundation of evidence-based guidelines may have significant clinical implications.     

Longitudinal change in end-digit preference in blood pressure recordings in the hypertension patients followed up in primary care clinics

ABSTRACT

Subject: This study was to evaluate whether a special lecture on the Chinese Guideline for Blood Pressure Measurement (CGBPM) improves end-digit preference (EDP) of blood pressure (BP) recordings in primary care clinics.

Methods: In 2012, the doctors working in a clinic received a lecture, which emphasizes that when mercurial sphygmomanometer was used, only 0, and even numbers could be recorded as BP end-digit. In 2016, we collected the BP recordings (2011–2015) of 462 hypertensive patients followed in the educated clinic or in another no-educated clinic. The percentages of 0, 2, 4, 6, 8 in BP end-digit were calculated for evaluating zero EDP, and the percent decline in each year was calculated on the formula: (baseline percentage – actual percentage in a year)/baseline percentage.

Results: In 2011, the percentage of zero end-digit was over 75% for SBP or DBP in both clinics. Against the no-educated clinic, the educated clinic had significant higher percent decline of zero EDP on SBP (31.5% vs ?2.6%) and DBP (36.9% vs ?14.3%) in 2013, and in 2014 (SBP 38.0% vs 11.6%; DBP 42.8% vs ?4.0%). In 2015, the educated clinic still had higher percent decline of zero EDP on DBP (43.3% vs 29.3%). Furthermore, the percentages of zero end-digit for SBP (43.6% vs 49.2%) or for DBP (43.5% vs 59.0%) were lower in the educated clinic in 2015.

Conclusion: Education on BP measurement and recording could improve the quality of BP recordings, and this effect may last for three years.     

Ambulatory blood pressure profiles of patients with permanent or occasional hypertension. Correlation with clinical data

Ambulatory blood pressure (BP) recording was performed in 57 untreated hypertensive patients by means of the "Spacelabs" non-invasive apparatus. Patients were divided into two groups according to BP measurements previously made during medical consultation. Group I comprised 25 "permanently hypertensive" patients (diastolic BP always above 95 mmHg) and group II, 32 "occasionally hypertensive" patients (diastolic BP sometimes normal, sometimes above 95 mmHg). The same circadian rhythm was observed in both groups. The mean ambulatory BP level was significantly higher (p less than 0.001) in group I patients than in group II patients, either over the whole of the 24-hour period (142.0/88.0 versus 122.7/75.3 mmHg), or in day time (149.0/92.5 versus 128.2/78.9 mmHg) or at night (128.0/80.1 versus 111.5/68.0 mmHg). In contrast, there did not seem to be any significant difference between the two groups in relative long-term variability of BP, expressed as the standard deviation/mean BP values ratio. Comparison with clinical data showed that BP values measured during consultation (160/103 mmHg in group I, 143/94 mmHg in group II) were higher than ambulatory values and, chiefly, that there was very poor correlation between the two measurement methods, precluding any extrapolation. Automatic ambulatory BP recording provides for more accurate evaluation of hypertensive patients, enabling emotional "artefacts" to be excluded and patients "reactivity" to their socio-professional environment to be assessed. However, in the absence of sufficient epidemiological data, doctors should not feel authorized to base their therapeutic decisions on the sole data supplied by ambulatory BP recordings.     

Which is the most accurate method of measuring blood pressure?

A blood pressure (BP) recording is, strictly speaking, only relevant for the circumstances under which it is measured. A reading that is truly representative of the average pressure is difficult to obtain because of the great variability of pressure in any person. The use to which BP readings are put should be defined, whether for characterizing populations, assessing antihypertensive agents, or managing individual patients. The limitations of any technique must be taken into account. Intra-arterial measurement of BP is the most accurate method, capable of giving a continuous picture. Indirect recordings give a rough estimate of intra-arterial pressure but less information about the relationship between individual subjects and their environment. Ambulatory indirect BP recordings with automated devices compare favorably in accuracy with conventional sphygmomanometers but contain more accurate characterization of an individual's BP during normal daily activities. The ultimate choice of method depends on what information is required in the particular circumstances.     

Home blood pressure measurement and its relationship with blood pressure control in a large selected hypertensive population

Despite the impressive increase of home blood pressure monitoring (BPM) among hypertensive patients over the last few years, a limited number of studies have analysed the rate of home BPM and its relationship with target blood pressure (BP) control, in representative samples of the hypertensive population. The objectives of the study were first to evaluate the prevalence of home BPM in a large selected group of treated hypertensive patients referred to our outpatient hypertension hospital clinic. Second, to assess the rate of satisfactory clinic BP control in patients with or without familiarity with home BPM. In all, 1350 consecutive hypertensive patients who attended our hypertension centre during a period of 12 months and were regularly followed up by the same medical team were included in the study. After informed consent all patients underwent the following procedures: (1) accurate medical history (implemented by a structured questionnaire on demographic and clinical characteristics, including questions concerning home BPM); (2) physical examination; (3) clinic BP measurement; (4) routine examinations; and (5) standard 12-lead electrocardiogram. A total of 897 patients (66%) out of 1350 (687 men, 663 women, age 58.6 +/- 12.3 years, mean clinic BP 141 +/- 16/87 +/- 9 mmHg ) were regularly practising home BPM. In this group of patients, home BPM was associated with a significantly greater rate of satisfactory BP control (49.2 vs 45.6%, P < 0.01). Patients performing home BPM were more frequently men (54 vs 46%, P < 0.02 ) younger (average age 57.8 +/- 12.0 vs 60.3 +/- 12.7 years, P < 0.001) and with a higher educational level (defined by more than 8 years of school, 71 vs 55%, P < 0.05) than their counterparts. There were no significant differences in duration of hypertension, hypercholesterolaemia, obesity, smoking, diabetes, associated cardiovascular diseases, left ventricular hypertrophy and compliance with drug treatment. This study demonstrates that: (1) home BPM is widely performed by hypertensive patients managed in a hypertension hospital clinic; (2) this practice is associated with a significantly higher rate of clinic BP control; and (3) age, male gender and educational level influence the adoption of home BPM.     

Severe Emotional Hypertension Compatible with 95-Year Lifespan and Little End-Organ Damage: 24-Year Record

We report on an interesting case of longevity in an elderly Japanese woman whose blood pressure (BP) continued extremely high from her first recording at the age of 38 years to her first hospitalization at the age of 81. BP recordings taken by her physician indicated mostly severe or occasionally mild hypertension (HT): between 260/130 and 140/76 mmHg. No antihypertensive drugs were taken during the 25 year span between ages 56 and 80. After her physician died, when she was 80, she changed clinicians and was given several kinds of antihypertensive drugs. She began to feel faintness, dizziness, and severe fatigue. At the time of the first hospitalization, no remarkable cerebral or cardiac abnormalities were observed, despite her BP as high as 210/110 mmHg. BP as measured by nurses or the physician in charge were always above 160/80 mmHg. After discharge, she was asked to measure BP by herself at home. These readings were 140–150/70–80 mmHg on the average, indicating a rare case of long-term emotional blood pressure response. The patient died not of a cerebrocardiovascular accident, but of acute renal failure at 95 years of age. Even though her recorded BP was extremely high when measured by medical staff members and still far above the current conventional desired limit of 120 mmHg systolic (S) BP or the earlier limit of 140 mmHg SBP, it was actually acceptable for her retrospectively, insofar as she lived to age 95. Although antihypertensive drug therapy may be helpful in some cases, it may not be necessary in others. Intensive drug therapy may even be harmful for misdiagnosed emotionally HT patients particularly those misdiagnosed with refractory hypertension, when the response to health care professionals may be emotional.     

Severe emotional hypertension compatible with 95-year lifespan and little end-organ damage: 24-year record

We report on an interesting case of longevity in an elderly Japanese woman whose blood pressure (BP) continued extremely high from her first recording at the age of 38 years to her first hospitalization at the age of 81. BP recordings taken by her physician indicated mostly severe or occasionally mild hypertension (HT): between 260/130 and 140/76 mmHg. No antihypertensive drugs were taken during the 25 year span between ages 56 and 80. After her physician died, when she was 80, she changed clinicians and was given several kinds of antihypertensive drugs. She began to feel faintness, dizziness, and severe fatigue. At the time of the first hospitalization, no remarkable cerebral or cardiac abnormalities were observed, despite her BP as high as 210/110 mmHg. BP as measured by nurses or the physician in charge were always above 160/80 mmHg. After discharge, she was asked to measure BP by herself at home. These readings were 140-150/70-80 mmHg on the average, indicating a rare case of long-term emotional blood pressure response. The patient died not of a cerebrocardiovascular accident, but of acute renal failure at 95 years of age. Even though her recorded BP was extremely high when measured by medical staff members and still far above the current conventional desired limit of 120 mmHg systolic (S) BP or the earlier limit of 140 mmHg SBP, it was actually acceptable for her retrospectively, insofar as she lived to age 95. Although antihypertensive drug therapy may be helpful in some cases, it may not be necessary in others. Intensive drug therapy may even be harmful for misdiagnosed emotionally HT patients particularly those misdiagnosed with refractory hypertension, when the response to health care professionals may be emotional.     

Lack of awareness of need to clean CFC-free metered-dose inhalers.

BACKGROUND: Chlorofluorocarbon (CFC)-free metered-dose inhalers (MDIs) were introduced into Australia in 1999. Device care instructions were modified (e.g., CFC-free salbutamol inhalers to be washed weekly), but this information was not communicated directly to health care professionals. OBJECTIVE: This pilot study aimed to assess the level of awareness of device care protocols for CFC-free MDIs by patients and their pharmacists. SETTING AND DESIGN: Purchasers of CFC-free MDIs were recruited from four community pharmacies. They were interviewed regarding information sources, knowledge of propellant change, and awareness of and adherence to device care protocols. The dispensing pharmacists were interviewed for knowledge of CFC-free device care. The primary outcome variable was awareness of the relevant device care protocol. RESULTS: Thirty-nine patients were interviewed. Most patients (77%) were aware of the change to CFC-free propellant. Only nine patients (23%) were aware of the need to wash the device holder, and four patients (10% of total) complied with the specified protocol. One of the ten dispensing pharmacists could describe correct device care protocols for the CFC-free MDIs. CONCLUSIONS: Although most patients are aware that MDIs are now CFC-free, there is a low level of awareness of the device care required for these inhalers, and a very low rate of compliance with recommended practice. Although the clinical impact of failing to wash the device holder is unclear, this added instruction may have substantial implications for patient satisfaction and medication delivery. Pharmaceutical manufacturers need to highlight to health care professionals any clinically important changes in device care instructions, so that appropriate information may be passed on to patients.     

Evaluation of blood pressure measurement and agreement in an academic health sciences center

The authors assessed the process of blood pressure (BP) measurement and level of adherence to recommended procedures at representative sites throughout a large academic health sciences center. A casual observer assessed the setting and observed the process, noting the equipment, technique, and BP recorded by site personnel. A trained observer then repeated the patient's BP measurement following American Heart Association recommendations. Significant biases were observed between measurements by site personnel and the trained observer. Site personnel reported on average an increased systolic BP (SBP) of 5.66 mm Hg (95% confidence interval [CI], 3.09-8.23; P<.001) and a decreased diastolic BP (DBP) of -2.96 mm Hg (95% CI, -5.05 to -0.87; P=.005). Overall, 41% of patients had a ≥10-mm Hg difference in SBP between measurements. Similarly, 54% had differences of ≥5 mm Hg in DBP between measurements. Inaccurate BP measurement and poor technique may lead to misclassification, misdiagnosis, and inappropriate medical decisions. Concordance of measured SBP between our site personnel and trained observer was less than optimal. Several areas for improvement were identified. Routine calibration and use of system-wide standardized equipment, establishment of BP measurement protocols, and periodic technique and equipment recertification can be addressed in future quality initiatives.     

Clinical value of monophasic action potentials

The method of monophasic action potential (MAP) recording has experienced a significant surge in interest since the introduction of the contact electrode, which in contrast to the suction electrode, allows the safe and simple use of this technique in the clinical electrophysiology laboratory. MAP recording not only provide for a more precise determination of local activation, but most importantly, permit direct measurement of myocardial repolarization and action potential duration (APD), respectively. This had led to new insights into the cycle-length-dependence of the human APD, both in response to single extrastimuli and to steady-state heart rate changes. An advancement of the contact electrode catheter design now permits simultaneous pacing and MAP recording, and thereby, simultaneous determinations of APD and effective refractory periods (EPP) at the same endocardial site in the human heart. MAP recordings have demonstrated significant usefulness in the direct monitoring of antiarrhythmic drug effects, both in terms of dosage control and in the direct measurement of antiarrhythmic drug effects on the relationship between ERP and APD (ERP/ARD-ratio). Because MAP recordings reflect the local cellular electrophysiology, they also provide a more sensitive and precise index of myocardial ischemia than conventional ECG recordings. This can be utilized to assess the success of revascularizing procedures directly during or after the intervention. Recently, MAP recordings helped to discover early after-depolarizations in patients with "torsade de pointes", providing a possible explanation for the mechanism of polymorphous ventricular tachycardia in man.     

Brief report: How well do clinic-based blood pressure measurements agree with the mercury standard?

BACKGROUND: Obtaining accurate blood pressure (BP) readings is a challenge faced by health professionals. Clinical trials implement strict protocols, whereas clinical practices and studies that assess quality of care utilize a less rigorous protocol for BP measurement. OBJECTIVE: To examine agreement between real-time clinic-based assessment of BP and the standard mercury assessment of BP. DESIGN: Prospective reliability study. PATIENTS: One hundred patients with an International Classification of Diseases-9th edition code for hypertension were enrolled. MEASURES: Two BP measurements were obtained with the Hawksley random-zero mercury sphygmomanometer and averaged. The clinic-based BP was extracted from the computerized medical records. RESULTS: Agreement between the mercury and clinic-based systolic blood pressure (SBP) was good, intraclass correlation coefficient (ICC)=0.91 (95% confidence interval (CI): 0.83 to 0.94); the agreement for the mercury and clinic-based diastolic blood pressure (DBP) was satisfactory, ICC=0.77 (95% CI: 0.62 to 0.86). Overall, clinic-based readings overestimated the mercury readings, with a mean overestimation of 8.3 mmHg for SBP and 7.1 mmHg for DBP. Based on the clinic-based measure, 21% of patients were misdiagnosed with uncontrolled hypertension. CONCLUSIONS: Health professionals should be aware of this potential difference when utilizing clinic-based BP values for making treatment decisions and/or assessing quality of care.     

Directly Observed Care: Can Unannounced Standardized Patients Address a Gap in Performance Measurement?

There are three potential sources of information for evaluating a clinician’s performance: documentation, patient report, and directly observed care. Current measures draw on just two of these: data recorded in the medical record and surveys of patients. Neither captures an array of performance characteristics, including clinician attention to symptoms and signs while taking a history or conducting a physical exam, accurate recording in the medical record of information obtained during the encounter, evidence based communication strategies for preventive care counseling, and effective communication behavior. Unannounced Standardized Patients (USPs) have been widely deployed as a research strategy for systematically uncovering significant performance deficits in each of these areas, but have not been adopted for quality improvement. Likely obstacles include concerns about the ethics of sending health professionals sham patients, the technical challenges of the subterfuge, and concerns about the relatively small sample sizes and substantial costs involved. However, the high frequency of significant and remediable performance deficits unmasked by USPs, and the potential to adapt registration and record keeping systems to accommodate their visits, suggest that their selective and purposeful deployment could be a cost effective and powerful strategy for addressing a gap in performance measurement.     

The effect of 24 h blood pressure levels on early neurological recovery after stroke

OBJECTIVES: To assess the influence of 24 h blood pressure (BP) levels on functional recovery 1 week after stroke and the effect of antihypertensive therapy on 24 h BP levels. DESIGN: Prospective study of patients admitted to hospital over 1 year with first in a lifetime stroke who underwent 24 h BP and casual measurements. Setting. Medical wards in a teaching hospital. Subjects. Of 160 patients, 72 patients admitted to hospital within 24 h of stroke onset were investigated. Patients with conditions and therapy that interfered with autonomic and sympathetic function were excluded. Interventions. All subjects underwent 24 h BP and casual recordings on admission to hospital and at day seven after stroke. The mean 24 h, day and night systolic BP (SBP) and diastolic BP (DBP) and their differences (nocturnal BP dip) were recorded. Patients were divided into three groups according to whether they were taking antihypertensive therapy during the first week: (i) no therapy, (ii) therapy continued after stroke, and (iii) new therapy introduced. Main outcome measures. Functional recovery (Rankin Scale 0-1) and neurological improvement [Scandinavian Stroke Scale (SSS) >/=3 points] by 1 week of stroke. Change in circadian 24 h BP over 1 week. RESULTS: For each 10 mmHg difference between day and night time DBP, the odds for making a complete recovery were 4.63 (95% CI: 1.57-13.7, P=0.01). For each 10 mmHg difference between day and night SBP, the odds for making an improvement in neurological status was 2.24 (95% CI: 1.16-4.32; P=0.016). Significant falls in 24 h DBP (P=0.01), daytime SBP (P=0.005) and mean arterial BP (MABP) (P=0.04) over 1 week were demonstrated in patients who had just commenced antihypertensive therapy (P=0.001). CONCLUSION: An increase in day to night time BP change is favourable in short-term outcome after acute stroke. Significant falls in BP are more likely in patients started on antihypertensive therapy for the first time. Further research is required to understand the effects of circadian BP rhythm on stroke outcome.     

Ambulatory 24-hour blood pressure monitoring in patients with resistant hypertension

The aim of the study was to assess the usefulness of 24-hour blood pressure (BP) and heart rate (HR) monitoring in patients with "resistant" hypertension. 30 patients (44.1 +/- 9.9 years) with diastolic BP 100 mm Hg or more in spite of treatment with three or more antihypertensive drugs were studied. Ambulatory recording of BP and HR was performed by means of Del Mar Avionics monitoring system 9000. Mean recording time was 21.5 hours and mean number of measurements during one recording--56.7. Mean ambulatory systolic and diastolic BP values were significantly lower than mean value of three casual measurements (146.0 +/- 24.6 vs 171.5 +/- 21.2 mm Hg for systolic and 97.2 +/- 11.3 vs 110.4 +/- 7.5 mm Hg for diastolic BP p less than 0.01) In 14 (46.6%) systolic BP and in 10 patients (33.3%) diastolic BP were normal. The patients with normal and abnormal ambulatory BP recordings did not differ in regard to age and mean clinic BP levels. However, patients with abnormal ambulatory BP recordings were more often overweight and showed a greater frequency of left ventricular hypertrophy and family history of hypertension and its complications. The results of the study show that ambulatory BP monitoring may be of value in assessing the response to antihypertensive treatment in patients with so called resistant hypertension as judged on the basis of clinic pressure.