Atrial Fibrillation Screening During Routine Automated Office, Home, and Ambulatory Blood Pressure Measurement: A Diagnostic Test Accuracy Systematic Review and Meta-Analysis.

BACKGROUND: Atrial fibrillation (AF) is often asymptomatic and undiagnosed. As AF and hypertension often coexist, opportunistic AF detection during routine automated blood pressure (BP) measurement appears to be an attractive screening method. METHODS: A systematic literature search was conducted to identify studies assessing the diagnostic test accuracy of office, home, or 24-hour ambulatory BP measuring devices with AF detection algorithms versus reference electrocardiography. Analyses were performed per participant (AF status based on several BP readings; most office/home devices) or per reading (AF status based on individual readings; all ambulatory devices). A meta-analysis stratified by device type (office/home/ambulatory) was conducted to calculate pooled measures of diagnostic accuracy. Sensitivity/meta-regression analyses were also performed. RESULTS: Among 3096 records initially retrieved, 23 diagnostic test accuracy studies were included. Data derived from 11 093 individuals (weighted age 69 years, males 56%, hypertensives 79%, diabetics 24%, and AF prevalence 17%) indicated a pooled sensitivity 0.97 (95% CI, 0.92-0.99), specificity 0.93 (95% CI, 0.90-0.95), and accuracy 0.93 (95% CI, 0.89-0.95), with generally consistent results using office, home, or ambulatory BP devices (slightly lower specificity with the latter). The positive and negative predictive values were 0.70 (95% CI, 0.60-0.80) and 0.99 (95% CI, 0.98-1.00), respectively. Sensitivity analyses indicated lower specificity in studies implementing reading versus participant analyses. Most studies presented a low risk of bias and minor applicability concerns. CONCLUSIONS: There is considerable and consistent evidence suggesting high diagnostic accuracy of AF detection algorithms implemented in automated BP monitors during routine BP measurements in and out of the office. AF diagnosis requires verification (electrocardiography) before treatment is administered.

Lifestyle management of hypertension: International Society of Hypertension position paper endorsed by the World Hypertension League and European Society of Hypertension.

Hypertension, defined as persistently elevated systolic blood pressure (SBP) >140 mmHg and/or diastolic blood pressure (DBP) at least 90 mmHg (International Society of Hypertension guidelines), affects over 1.5 billion people worldwide. Hypertension is associated with increased risk of cardiovascular disease (CVD) events (e.g. coronary heart disease, heart failure and stroke) and death. An international panel of experts convened by the International Society of Hypertension College of Experts compiled lifestyle management recommendations as first-line strategy to prevent and control hypertension in adulthood. We also recommend that lifestyle changes be continued even when blood pressure-lowering medications are prescribed. Specific recommendations based on literature evidence are summarized with advice to start these measures early in life, including maintaining a healthy body weight, increased levels of different types of physical activity, healthy eating and drinking, avoidance and cessation of smoking and alcohol use, management of stress and sleep levels. We also discuss the relevance of specific approaches including consumption of sodium, potassium, sugar, fibre, coffee, tea, intermittent fasting as well as integrated strategies to implement these recommendations using, for example, behaviour change-related technologies and digital tools.

Chlorthalidone versus hydrochlorothiazide for preventing cardiovascular disease in hypertension: Is the case closed?

The optimal diuretic choice [hydrochlorothiazide (HCTZ) or chlorthalidone (CTD)] for the management of hypertension has been an ongoing debate for several years. HCTZ is widely used in the form of single-pill combinations, whereas CTD is a more potent drug vs. HCTZ, especially in reducing nighttime blood pressure (BP), with some indirect evidence suggesting a superiority in terms of cardiovascular (CV) risk reduction. In addition, recent data showed that CTD was safe and effective in terms of BP lowering in predialysis patients with stage 4 chronic kidney disease. The Diuretic Comparison Project was the first head-to-head pragmatic, open-label trial that randomly assigned elderly patients with hypertension under HCTZ therapy to continue with HCTZ or to switch to CTD (equivalent doses). Office BP was similar for both groups throughout the study. The trial showed no difference in major CV events or non-cancer-related deaths during a median follow-up of 2.4 years; yet, CTD was associated with a benefit in participants with a previous myocardial infarction or stroke, which might be a chance finding but could also indicate that a high-risk population is more suitable for revealing the impact of slight differences in the 24-hour BP profile in a relatively short-term follow-up. Interestingly CTD vs. HCTZ was associated with higher hypokalemia rates apart from the latter group of patients where there was no difference. Overall, the available data do not confirm the superiority of CTD over HCTZ in general, but this could be questionable in selected patients.

Blood pressure variability assessed by office, home, and ambulatory measurements: comparison, agreement, and determinants.

The present study compared the blood pressure variability (BPV) among office (OBP), home (HBP), and ambulatory blood pressure (ABP) measurements and assessed their determinants, as well as their agreement in identifying individuals with high BPV. Individuals attending a hypertension clinic had OBP measurements (2-3 visits) and underwent HBP monitoring (3-7 days, duplicate morning and evening measurements) and ABP monitoring (24 h, 20-min intervals). BPV was quantified using the standard deviation (SD), coefficient of variation (CV), and variability independent of the mean (VIM) using all BP readings obtained by each method. A total of 626 participants were analyzed (age 52.8 ± 12.0 years, 57.7% males, 33.1% treated). Systolic BPV was usually higher than diastolic BPV, and out-of-office BPV was higher than office BPV, with ambulatory BPV giving the highest values. BPV was higher in women than men, yet it was not different between untreated and treated individuals. Associations among BPV indices assessed using different measurement methods were weak (r 0.1-0.3) but were stronger between out-of-office BPV indices. The agreement between methods in detecting individuals with high BPV was low (30-40%) but was higher between out-of-office BPV indices. Older age was an independent determinant of increased OBP variability. Older age, female sex, smoking, and overweight/obesity were determinants of increased out-of-office BPV. These data suggest that BPV differs with different BP measurement methods, reflecting different pathophysiological phenomena, whereas the selection of the BPV index is less important. Office and out-of-office BP measurements appear to be complementary methods in assessing BPV.

Prospective meta-analysis protocol on randomised trials of renin-angiotensin system inhibitors in patients with COVID-19: an initiative of the International Society of Hypertension.

INTRODUCTION: Whether ACE inhibitors (ACEi) or angiotensin II receptor blocker (ARB) therapy should be continued, initiated or ceased in patients with COVID-19 is uncertain. Given the widespread use of ACEi/ARBs worldwide, guidance on the use of these drugs is urgently needed. This prospective meta-analysis aims to pool data from randomised controlled trials (RCTs) to assess the safety and efficacy of ACEi/ARB therapy in adults infected with SARS-CoV-2. METHODS AND ANALYSIS: RCTs will be eligible if they compare patients with COVID-19 randomised to ACEi/ARB continuation or commencement versuss no ACEi/ARB therapy; study duration ≥14 days; recruitment completed between March 2020 and May 2021. The primary outcome will be all-cause mortality at ≤30 days. Secondary outcomes will include mechanical ventilation, admission to intensive care or cardiovascular events at short-term follow-up (≤30 days) and all-cause mortality at longer-term follow-up (>1 month). Prespecified subgroup analyses will assess the effect of sex; age; comorbidities; smoking status; ethnicity; country of origin on all-cause mortality. A search of ClinicalTrials.gov has been performed, which will be followed by a formal search of trial registers, preprint servers, MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials to identify RCTs that meet inclusion criteria. To date, a search of ClinicalTrials.gov identified 21 potentially eligible trials for this meta-analysis. We will request trial investigators/sponsors to contribute standardised grouped tabular outcome data. ETHICS AND DISSEMINATION: Ethics approval and informed consent will be the responsibility of the individual RCTs. Dissemination of results will occur by peer-reviewed publication. The results of our analysis can inform public health policy and clinical decision making regarding ACEi/ARB use in patients with COVID-19 on a global scale.

High prevalence of cardiovascular risk factors in adults living in Greece: the EMENO National Health Examination Survey.

BACKGROUND: Nationwide data on cardiovascular risk factors prevalence is lacking in Greece. This work presents the findings of the national health examination survey EMENO (2013-2016) regarding the prevalence of hypertension, hypercholesterolemia, diabetes, obesity and smoking. METHODS: A random sample of adults (≥18 years) was drawn by multistage stratified random sampling based on 2011 Census. All EMENO participants with ≥1 measurement of interest [blood pressure (BP), fasting glucose, HbA1c, total cholesterol (TC), Body Mass Index (BMI)] were included. Hypertension was defined as BP ≥ 140/90 mmHg and/or antihypertensive treatment; diabetes as fasting glucose≥126 mg/dL and/or HbA1c ≥ 6.5% or self-reported diabetes; hypercholesterolemia as TC ≥ 190 mg/dL. Sampling weights were applied to adjust for study design and post-stratification weights to match sample age and sex distribution to population one. Non-response was adjusted by inverse probability weighting. RESULTS: Of 6006 EMENO participants, 4822 were included (51.5% females, median age:47.9 years). The prevalence of hypertension was 39.2%, higher in men (42.4%) than in women (36.1%); of hypercholesterolemia 60.2%, similar in men (59.5%) and women (60.9%); of diabetes 11.6%, similar men (12.4%) and women (10.9%); of obesity 32.1%, higher in women (33.5% vs 30.2%), although in subjects aged 18-40 year it was higher in men; of current smoking 38.2%, higher in men (44.0%) than in women (32.7%). The prevalence of all risk factors increased substantially with age, except smoking, which followed an inverse U shape. CONCLUSIONS: The burden of cardiovascular risk factors among Greek adults is alarming. There is considerable preventive potential and actions at health care and societal level are urgently needed.

Pregnancy-Related Complications in Patients With Fibromuscular Dysplasia: A Report From the European/International Fibromuscular Dysplasia Registry.

Current literature suggests a higher risk of pregnancy-related complications in patients with renal fibromuscular dysplasia (FMD). The aim of our study was to assess the nature and prevalence of pregnancy-related complications in patients subsequently diagnosed with FMD. A call for participation was sent to centers contributing to the European/International FMD Registry. Patients with at least 1 pregnancy were included. Data on pregnancy were collected through medical files and FMD characteristics through the European/International FMD Registry. Data from 534 pregnancies were obtained in 237 patients. Despite the fact that, in 96% of cases, FMD was not diagnosed before pregnancy, 40% of women (n=93) experienced pregnancy-related complications, mostly gestational hypertension (25%) and preterm birth (20%), while preeclampsia was reported in only 7.5%. Only 1 patient experienced arterial dissection and another patient an aneurysm rupture. When compared with patients without pregnancy-related complications, patients with complicated pregnancies were younger at FMD diagnosis (43 versus 51 years old; P<0.001) and had a lower prevalence of cerebrovascular FMD (30% versus 52%; P=0.003) but underwent more often renal revascularization (63% versus 40%, P<0.001). In conclusion, the prevalence of pregnancy-related complications such as gestational hypertension and preterm birth was high in patients with FMD, probably related to the severity of renal FMD. However, the prevalence of preeclampsia and arterial complications was low/moderate. These findings emphasize the need to screen hypertensive women for FMD to ensure revascularization before pregnancy if indicated and appropriate follow-up during pregnancy, without discouraging patients with FMD from considering pregnancy.

May Measurement Month 2019: The Global Blood Pressure Screening Campaign of the International Society of Hypertension.

Elevated blood pressure remains the single biggest risk factor contributing to the global burden of disease and mortality. May Measurement Month is an annual global screening campaign aiming to improve awareness of blood pressure at the individual and population level. Adults (≥18 years) recruited through opportunistic sampling were screened at sites in 92 countries during May 2019. Ideally, 3 blood pressure readings were measured for each participant, and data on lifestyle factors and comorbidities were collected. Hypertension was defined as a systolic blood pressure ≥140 mm Hg, or a diastolic blood pressure ≥90 mm Hg (mean of the second and third readings) or taking antihypertensive medication. When necessary, multiple imputation was used to estimate participants' mean blood pressure. Mixed-effects models were used to evaluate associations between blood pressure and participant characteristics. Of 1 508 130 screenees 482 273 (32.0%) had never had a blood pressure measurement before and 513 337 (34.0%) had hypertension, of whom 58.7% were aware, and 54.7% were on antihypertensive medication. Of those on medication, 57.8% were controlled to <140/90 mm Hg, and 28.9% to <130/80 mm Hg. Of all those with hypertension, 31.7% were controlled to <140/90 mm Hg, and 350 825 (23.3%) participants had untreated or inadequately treated hypertension. Of those taking antihypertensive medication, half were taking only a single drug, and 25% reported using aspirin inappropriately. This survey is the largest ever synchronized and standardized contemporary compilation of global blood pressure data. This campaign is needed as a temporary substitute for systematic blood pressure screening in many countries worldwide.

Optimización del desempeño del observador al medir la presión arterial en el consultorio: declaración de posición de la Comisión Lancet de Hipertensión / Optimizing observer performance of clinic blood Pressure measurement: a position statement from the Lancet Commission on Hypertension Group / Otimização do desempenho do observador na medição clínica da pressão arterial: posicionamento do Grupo da Lancet Commission on Hypertension

RESUMEN La hipertensión arterial es una causa modificable muy prevalente de enfermedades cardiovasculares, accidentes cerebrovasculares y muerte. Medir con exactitud la presión arterial es fundamental, dado que un error de medición de 5 mmHg puede ser motivo para clasificar incorrectamente como hipertensas a 84 millones de personas en todo el mundo. En la presente declaración de posición se resumen los procedimientos para optimizar el desempeño del observador al medir la presión arterial en el consultorio, con atención especial a los entornos de ingresos bajos o medianos, donde esta medición se ve complicada por limitaciones de recursos y tiempo, sobrecarga de trabajo y falta de suministro eléctrico. Es posible reducir al mínimo muchos errores de medición con una preparación adecuada de los pacientes y el uso de técnicas estandarizadas. Para simplificar la medición y prevenir errores del observador, deben usarse tensiómetros semiautomáticos o automáticos de manguito validados, en lugar del método por auscultación. Pueden ayudar también la distribución de tareas, la creación de un área específica de medición y el uso de aparatos semiautomáticos o de carga solar. Es fundamental garantizar la capacitación inicial y periódica de los integrantes del equipo de salud. Debe considerarse la implementación de programas de certificación de bajo costo y fácilmente accesibles con el objetivo de mejorar la medición de la presión arterial.(AU)

ABSTRACT High blood pressure (BP) is a highly prevalent modifiable cause of cardiovascular disease, stroke, and death. Accurate BP measurement is critical, given that a 5-mmHg measurement error may lead to incorrect hypertension status classification in 84 million individuals worldwide. This position statement summarizes procedures for optimizing observer performance in clinic BP measurement, with special attention given to low-tomiddle- income settings, where resource limitations, heavy workloads, time constraints, and lack of electrical power make measurement more challenging. Many measurement errors can be minimized by appropriate patient preparation and standardized techniques. Validated semi-automated/automated upper arm cuff devices should be used instead of auscultation to simplify measurement and prevent observer error. Task sharing, creating a dedicated measurement workstation, and using semi-automated or solar-charged devices may help. Ensuring observer training, and periodic re-training, is critical. Low-cost, easily accessible certification programs should be considered to facilitate best BP measurement practice.(AU)

RESUMO A hipertensão é uma causa altamente prevalente de doença cardiovascular, acidente vascular cerebral e morte. A medição precisa da pressão arterial (PA) é um aspecto crítico, uma vez que erros de mensuração da ordem de 5 mmHg podem levar a uma classificação incorreta do status de hipertensão em 84 milhões de pessoas em todo o mundo. O presente posicionamento resume os procedimentos para otimizar o desempenho do observador (o indivíduo responsável pela mensuração da PA) na mensuração clínica da PA, com atenção especial para contextos de baixa a média renda, onde recursos limitados, cargas de trabalho pesadas, restrições de tempo e falta de energia elétrica tornam mais desafiadora a tarefa de medir a PA. Muitos erros de mensuração podem ser minimizados pela preparação adequada do paciente e pelo uso de técnicas padronizadas. Para simplificar a mensuração e evitar erros do observador, devem-se utilizar dispositivos semiautomatizados ou automatizados validados, com manguito para braço, ao invés de auscultação. O compartilhamento de tarefas, a criação de uma estação de trabalho dedicada à mensuração e o uso de dispositivos semiautomatizados ou com carga solar podem ajudar. É essencial que seja assegurado o treinamento e retreinamento periódico do observador. Programas de certificação de baixo custo e de fácil acesso devem ser considerados para facilitar a adoção das melhores práticas na mensuração da PA.(AU)

Declaración de posición del Grupo de la Comisión Lancet de Hipertensión con respecto a la mejora mundial de las normas de exactitud para los dispositivos de medición de la presión arterial / Lancet Commission on Hypertension Group position statement on the global improvement of accuracy standards for devices that measure blood pressure / Posicionamento do Grupo da Lancet Commission on Hypertension sobre a melhoria global dos padrões de acurácia para aparelhos que medem a pressão arterial

Objetivos. El boletín de notas de México correspondiente al 2018 evalúa las oportunidades a disposición de la población infantil y joven mexicana para que puedan desarrollar niveles adecuados de actividad física y sueño, y disminuyan el sedentarismo.Métodos. El boletín es un sistema de vigilancia que recopila los datos obtenidos en las encuestas nacionales, censos, documentos gubernamentales, sitios web, literatura gris y estudios publicados con respecto al análisis de 16 indicadores en 4 categorías: comportamientos diarios, estado físico, entornos y fuentes influyentes, y estrategias e inversión. Los datos fueron cotejados con los puntos de referencia establecidos. A cada indicador se le asignó una calificación entre 1 y 10 (< 6 significa reprobado) o fue marcado como "incompleto" si los datos eran nulos o insuficientes. Resultados. Las calificaciones obtenidas para los comportamientos diarios fueron: actividad física en general: 4; participación en actividades deportivas organizadas: 5; juego activo: 3; modalidades de transporte activas: 5; sueño: 7; y sedentarismo: 3. El estado físico obtuvo un 7. Las calificaciones para los entornos y fuentes influyentes fueron: familiares y pares: "incompleto"; escuela: 3; comunidad y entorno: 4. Para las estrategias e inversión: estrategias gubernamentales: 6; entidades no gubernamentales: 2.Conclusiones. Las bajas calificaciones obtenidas en 11 de los 16 indicadores demuestran que las escuelas, las familias, las comunidades y el gobierno tienen que aunar esfuerzos para mejorar las oportunidades que tiene la población infantil y joven en México para desarrollar niveles de actividad física satisfactorios.(AU)

ABSTRACT The Lancet Commission on Hypertension identified that a key action to address the worldwide burden of high blood pressure (BP) was to improve the quality of BP measurements by using BP devices that have been validated for accuracy. Currently, there are over 3 000 commercially available BP devices, but many do not have published data on accuracy testing according to established scientific standards. This problem is enabled through weak or absent regulations that allow clearance of devices for commercial use without formal validation. In addition, new BP technologies have emerged (e.g. cuffless sensors) for which there is no scientific consensus regarding BP measurement accuracy standards. Altogether, these issues contribute to the widespread availability of clinic and home BP devices with limited or uncertain accuracy, leading to inappropriate hypertension diagnosis, management and drug treatment on a global scale. The most significant problems relating to the accuracy of BP devices can be resolved by the regulatory requirement for mandatory independent validation of BP devices according to the universally-accepted International Organization for Standardization Standard. This is a primary recommendation for which there is an urgent international need. Other key recommendations are development of validation standards specifically for new BP technologies and online lists of accurate devices that are accessible to consumers and health professionals. Recommendations are aligned with WHO policies on medical devices and universal healthcare. Adherence to recommendations would increase the global availability of accurate BP devices and result in better diagnosis and treatment of hypertension, thus decreasing the worldwide burden from high BP.(AU)

RESUMO A Comissão Lancet sobre Hipertensão Arterial identificou que uma iniciativa central para enfrentar a carga mundial da hipertensão arterial seria a melhoria na qualidade da mensuração da pressão arterial pelo uso aparelhos de pressão arterial validados quanto à acurácia. Atualmente, existem mais de 3 000 aparelhos de pressão arterial disponíveis comercialmente; entretanto, muitos não têm dados publicados sobre testes de acurácia realizados de acordo com padrões científicos estabelecidos. Este problema resulta de regulamentação fraca ou inexistente, o que permite a aprovação para uso comercial de dispositivos sem validação formal. Além disso, surgiram novas tecnologias de mensuração da pressão arterial (por exemplo, sensores sem algemas) sem consenso científico quanto aos padrões de acurácia. No conjunto, essas questões contribuem para a oferta generalizada de dispositivos de pressão arterial clínica e domiciliar com acurácia limitada ou incerta, levando a diagnóstico, gerenciamento e tratamento inadequados da hipertensão em escala global. Os problemas mais significativos relacionados com a acurácia dos dispositivos de pressão arterial podem ser resolvidos por regulamentação que imponha a obrigatoriedade de validação independente dos aparelhos de pressão arterial, de acordo com a norma universalmente aceita pela Organização Internacional de Normalização. Esta é uma recomendação fundamental para a qual existe uma necessidade internacional urgente. Outras recomendações essenciais incluem o desenvolvimento de padrões de validação especificamente para novas tecnologias de mensuração da pressão arterial e listas on-line de aparelhos com acurácia adequada que sejam acessíveis aos consumidores e profissionais de saúde. As recomendações estão alinhadas com as políticas da Organização Mundial da Saúde (OMS) sobre dispositivos médicos e atenção universal à saúde. A adesão às recomendações aumentaria a oferta global de dispositivos de pressão arterial com acurácia adequada e resultaria em melhor diagnóstico e tratamento da hipertensão arterial, diminuindo assim a carga mundial dessa doença.(AU)

Diagnostic accuracy of a novel cuffless self-blood pressure monitor for atrial fibrillation screening in the elderly.

Blood pressure (BP) monitors equipped with atrial fibrillation (AF) detection algorithm are attractive screening tools for AF in elderly hypertensives. This study assessed the diagnostic accuracy of a novel cuffless pocket-size self-BP monitor (Freescan, Maisense) equipped with an AF detection algorithm, which displays results for the detection of "AF" or "Arrhythmia" during routine BP measurement. Subjects aged >65 years or 60-65 years with hypertension, diabetes, or cardiovascular disease were subjected to BP measurements using the Freescan device with simultaneous continuous Holter electrocardiography (ECG) monitoring. Readings with device notification "Instability" (29%) or "Error" (20%) were discarded. Data from 136 subjects with five valid Freescan BP measurements were analyzed (age 73.8 ± 7.1 years, males 63%, treated hypertensives 88%, AF in ECG 21%). Analysis of 680 Freescan readings vs ECG revealed specificity 99%, sensitivity 67%, and diagnostic accuracy 93% for AF diagnosis. When the "Arrhythmia" notification was considered as AF diagnosis, the sensitivity was improved (93%, 96%, and 93%, respectively). Analysis of AF diagnosis in subjects (diagnosis defined as at least three of five readings indicating "AF" or "Arrhythmia") revealed specificity, sensitivity, and diagnostic accuracy for AF detection at 94%, 100%, and 95%, respectively. These data suggest that the Freescan cuffless device could be used as a useful screening tool for AF detection during routine self-measurement of BP in the elderly.

National Survey of Morbidity and Risk Factors (EMENO): Protocol for a Health Examination Survey Representative of the Adult Greek Population.

BACKGROUND: Main causes of death in Greece are cardiovascular diseases (CVDs), malignant neoplasms, respiratory diseases, and road traffic crashes. To assess the population health status, monitor health systems, and adjust policies, national population-based health surveys are recommended. The previous health surveys that were conducted in Greece were restricted to specific regions or high-risk groups. OBJECTIVE: This paper presents the design and methods of the Greek Health Examination Survey EMENO (National Survey of Morbidity and Risk Factors). The primary objectives are to describe morbidity (focusing on CVD, respiratory diseases, and diabetes), related risk factors, as well as health care and preventive measures utility patterns in a random sample of adults living in Greece. METHODS: The sample was selected by applying multistage stratified random sampling on 2011 Census. Trained interviewers and physicians made home visits. Standardized questionnaires were administered; physical examination, anthropometric and blood pressure measurements, and spirometry were performed. Blood samples were collected for lipid profile, glucose, glycated hemoglobin, and transaminases measurements. The survey was conducted from May 2013 until June 2016. RESULTS: In total, 6006 individuals were recruited (response rate 72%). Of these, 4827 participated in at least one physical examination, 4446 had blood tests, and 3622 spirometry, whereas 3580 provided consent for using stored samples for future research (3528 including DNA studies). Statistical analysis has started, and first results are expected to be submitted for publication by the end of 2018. CONCLUSIONS: EMENO comprises a unique health data resource and a bio-resource in a Mediterranean population. Its results will provide valid estimates of morbidity and risk factors' prevalence (overall and in specific subdomains) and health care and preventive measures usage in Greece, necessary for an evidence-based strategy planning of health policies and preventive activities. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/10997.

Guidelines for blood pressure measurement: development over 30 years.

In the last 2 decades, several scientific societies have published specific guidelines for blood pressure (BP) measurement, providing detailed recommendations for office, home, and ambulatory BP monitoring. These documents typically provided strong support for using out-of-office BP monitoring (ambulatory and home). More recently, several organizations recommended out-of-office BP evaluation as a primary method for diagnosing hypertension and for treatment titration, with office BP regarded as a screening method. Efforts should now be directed towards making ambulatory and home BP monitoring readily available in primary care and ensuring that such measurements are obtained by following current guidelines. Moreover, it should be mandatory for all published clinical research papers on hypertension to provide details on the methodology of the BP measurement.

Visit-to-Visit Office Blood Pressure Variability and Cardiovascular Outcomes in SPRINT (Systolic Blood Pressure Intervention Trial).

Studies of visit-to-visit office blood pressure (BP) variability (OBPV) as a predictor of cardiovascular events and death in high-risk patients treated to lower BP targets are lacking. We conducted a post hoc analysis of SPRINT (Systolic Blood Pressure Intervention Trial), a well-characterized cohort of participants randomized to intensive (<120 mm Hg) or standard (<140 mm Hg) systolic BP targets. We defined OBPV as the coefficient of variation of the systolic BP using measurements taken during the 3-,6-, 9-, and 12-month study visits. In our cohort of 7879 participants, older age, female sex, black race, current smoking, chronic kidney disease, and coronary disease were independent determinants of higher OBPV. Use of thiazide-type diuretics or dihydropyridine calcium channel blockers was associated with lower OBPV whereas angiotensin-converting enzyme inhibitors or angiotensin receptor blocker use was associated with higher OBPV. There was no difference in OBPV in participants randomized to standard or intensive treatment groups. We found that OBPV had no significant associations with the composite end point of fatal and nonfatal cardiovascular events (n=324 primary end points; adjusted hazard ratio, 1.20; 95% confidence interval, 0.85-1.69, highest versus lowest quintile) nor with heart failure or stroke. The highest quintile of OBPV (versus lowest) was associated with all-cause mortality (adjusted hazard ratio, 1.92; confidence interval, 1.22-3.03) although the association of OBPV overall with all-cause mortality was marginal (P=0.07). Our results suggest that clinicians should continue to focus on office BP control rather than on OBPV unless definitive benefits of reducing OBPV are shown in prospective trials. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01206062.

Associations between obesity, adverse behavioral patterns and cardiovascular risk factors among adolescent inhabitants of a Greek island.

BACKGROUND: Excess weight, unhealthy lifestyle habits and their sequelae have become a well-recognized public health problem in most countries. The objective of the study was to examine the relationship of adolescent overweight/obesity with behavioral habits and their association with blood pressure (BP) and lipid profile. METHODS: Anthropometric parameters, lifestyle, BP and lipid profile of 736 adolescents were evaluated cross-sectionally. The classifications of normal weight, overweight and obese were based on BMI z-scores. RESULTS: About 42.1% of adolescents were overweight/obese, 11.3% were smokers, 33.2% consumed alcohol and 34% reported low activity. Males began smoking earlier, consumed alcohol more often, exercised less and spent more screen time than females. Alcohol consumption was more prevalent among smokers and was associated with higher BP and dyslipidemia. Smokers exercised less intensely and had lower high density lipoprotein-cholesterol (HDL-C) than non-smokers. Obesity was a risk factor for higher BP and dyslipidemia. Longer screen time was associated with higher triglycerides, while intense physical activity with lower systolic BP. CONCLUSIONS: Obesity is related to an adverse lipid and BP profile during adolescence. Clustering of hazardous habits was observed, which is known to aggravate the cardiovascular risk.

Hypertension types defined by clinic and ambulatory blood pressure in 14 143 patients referred to hypertension clinics worldwide. Data from the ARTEMIS study.

OBJECTIVE: The Ambulatory blood pressure Registry TEleMonitoring of hypertension and cardiovascular rISk project was designed to set up an international registry including clinic blood pressure (CBP) and ambulatory blood pressure (ABP) measurements in patients attending hypertension clinics in all five continents, aiming to assess different daily life hypertension types. METHODS: Cross-sectional ABP, CBP and demographic data, medical history and cardiovascular risk profile were provided from existing databases by hypertension clinics. Hypertension types were evaluated considering CBP (≥140/90 mmHg) and 24-h ABP (≥130/80 mmHg). RESULTS: Overall, 14 143 patients from 27 countries across all five continents were analyzed (Europe 73%, Africa 3%, America 9%, Asia 14% and Australia 2%). Mean age was 57 ±â€Š14 years, men 51%, treated for hypertension 46%, cardiovascular disease 14%, people with diabetes 14%, dyslipidemia 33% and smokers 19%. The prevalence of hypertension was higher by CBP than by ABP monitoring (72 vs. 60%, P < 0.0001). Sustained hypertension (elevated CBP and ABP) was detected in 49% of patients. White-coat hypertension (WCH, elevated CBP with normal ABP) was more common than masked hypertension (elevated ABP with normal CBP) (23 vs. 10%; P < 0.0001). Sustained hypertension was more common in Europe and America and in elderly, men, obese patients with cardiovascular comorbidities. WCH was less common in Australia, America and Africa, and more common in elderly, obese women. Masked hypertension was more common in Asia and in men with diabetes. Smoking was a determinant for sustained hypertension and masked hypertension. CONCLUSION: Our analysis showed an unbalanced distribution of WCH and masked hypertension patterns among different continents, suggesting an interplay of genetic and environmental factors, and likely also different healthcare administrative and practice patterns.

Quantifying the economic benefits of prevention in a healthcare setting with severe financial constraints: the case of hypertension control.

Hypertension significantly contributes to the increased cardiovascular morbidity and mortality, thus leading to rising healthcare costs. The objective of this study was to quantify the clinical and economic benefits of optimal systolic blood pressure (SBP), in a setting under severe financial constraints, as in the case of Greece. Hence, a Markov model projecting 10-year outcomes and costs was adopted, in order to compare two scenarios. The first one depicted the "current setting", where all hypertensives in Greece presented an average SBP of 164 mmHg, while the second scenario namely "optimal SBP control" represented a hypothesis in which the whole population of hypertensives would achieve optimal SBP (i.e. <140 mmHg). Cardiovascular events' occurrence was estimated for four sub-models (according to gender and smoking status). Costs were calculated from the Greek healthcare system's perspective (discounted at a 3% annual rate). Findings showed that compared to the "current setting", universal "optimal SBP control" could, within a 10-year period, reduce the occurrence of non-fatal events and deaths, by 80 and 61 cases/1000 male smokers; 59 and 37 cases/1000 men non-smokers; whereas the respective figures for women were 69 and 57 cases/1000 women smokers; and accordingly, 52 and 28 cases/1000 women non-smokers. Considering health expenditures, they could be reduced by approximately €83 million per year. Therefore, prevention of cardiovascular events through BP control could result in reduced morbidity, thereby in substantial cost savings. Based on clinical and economic outcomes, interventions that promote BP control should be a health policy priority.

Asleep home blood pressure monitoring in obstructive sleep apnea: a pilot study.

BACKGROUND: Obstructive sleep apnea (OSA) is known to be related to nocturnal blood pressure (BP) and nondipping hypertension. This pilot study evaluated night-time BP assessed using a home monitor in patients with OSA. PARTICIPANTS AND METHODS: Patients referred to a sleep clinic were subjected to polysomnography, clinic BP measurements, and home BP monitoring using a device that allows daytime (3 days, two duplicate readings per day) and automated night-time BP measurement (3 nights, three readings per night). RESULTS: Thirty-nine patients were included [72% men, mean age 48.7±10.8 years, clinic BP 131.2±19.6/84.1±11.9 mmHg, apnea-hypopnea index (AHI): 35.2±25.7]. All BP measurements were significantly correlated with the polysomnography indices. There was a consistent trend toward stronger correlations of the night-time diastolic home BP with the AHI (r=0.56), the duration of desaturation (0.53), and the maximum (-0.57) and minimum (-0.48) arterial oxygen saturation (all P<0.001). In stepwise multivariate analysis (independent variables age, sex, body weight, smoking status, and BP parameters), the AHI was associated independently with weight and night-time diastolic home BP (R=0.53). CONCLUSION: In patients with OSA, the assessment of night-time BP using a home monitor appears to be feasible and related to the severity of OSA. Given the wide availability of home BP monitoring in clinical practice, this method appears to be useful in the evaluation of BP in patients with OSA.

Automated determination of the ankle-brachial index using an oscillometric blood pressure monitor: validation vs. Doppler measurement and cardiovascular risk factor profile.

The ankle-brachial index (ABI) is a method used widely for peripheral arterial disease (PAD) diagnosis and cardiovascular risk prediction. This study validated automated ABI measurements taken using an oscillometric blood pressure (BP) monitor allowing simultaneous arm-leg BP measurements. A total of 93 patients (hypertension 83%; dyslipidemia 72%; diabetes 45%; cardiovascular disease 23%; smoking 15%) were submitted to Doppler and automated ABI measurements, performed using a professional oscillometric BP monitor (Microlife WatchBP Office; triplicate simultaneous arm-leg BP measurements), in a randomized order. The mean difference between the Doppler reading (1.08 ± 0.17) and (1) the first oscillometric ABI reading was 0.03 ± 0.11, (2) the average of two oscillometric readings was 0.02 ± 0.10 and (3) the average of three oscillometric readings was 0.02 ± 0.09 (P < 0.01 for all). Strong correlations were found between oscillometric and Doppler ABI (r 0.80, 0.85 and 0.86 for single and average of two and three oscillometric readings, respectively; P < 0.001 for all). Agreement between oscillometric and Doppler ABI in diagnosing PAD (Doppler ABI < 0.9) was found in 95% of cases (κ 0.79; agreement in diabetics: 94%, κ 0.79). A receiver operating characteristic (ROC) curve revealed area under the curve at 0.98, with a 0.97 oscillometric ABI cutoff for optimal sensitivity (92%) and specificity (92%) in diagnosing PAD. Average time for automated ABI measurement was 5.8 vs. 9.3 min for Doppler (P < 0.001). Doppler and oscillometric ABI were associated and predicted (multivariate regression analysis) by the same cardiovascular risk factors (pulse pressure, smoking and cardiovascular disease history). Automated ABI measurement using a professional BP monitor allowing simultaneous arm-leg BP measurements appears to be a reliable and faster alternative to Doppler measurement.