A novel concept: cardiovascular assessment of hypertensive patients in pharmacies.

A range of cardiovascular investigations is required for the effective management of hypertension. To obtain these investigations my require the patient having to attend many facilities. A scheme for performing basic cardiovascular investigations in pharmacies is proposed.

Prevalence and Determinants of Masked Hypertension Among Black Nigerians Compared With a Reference Population.

Hitherto, diagnosis of hypertension in sub-Saharan Africa was largely based on conventional office blood pressure (BP). Data on the prevalence of masked hypertension (MH) in this region is scarce. Among individuals with normal office BP (<140/90 mm Hg), we compared the prevalence and determinants of MH diagnosed with self-monitored home blood pressure (≥135/85 mm Hg) among 293 Nigerians with a reference population consisting of 3615 subjects enrolled in the International Database on Home Blood Pressure in Relation to Cardiovascular Outcomes. In the reference population, the prevalence of MH was 14.6% overall and 11.1% and 39.6% in untreated and treated participants, respectively. Among Nigerians, the prevalence standardized to the sex and age distribution of the reference population was similar with rates of 14.4%, 8.6%, and 34.6%, respectively. The mutually adjusted odds ratios of having MH in Nigerians were 2.34 (95% confidence interval, 1.39-3.94) for a 10-year higher age, 1.92 (1.11-3.31) and 1.70 (1.14-2.53) for 10- or 5-mm Hg increments in systolic or diastolic office BP, and 3.05 (1.08-8.55) for being on antihypertensive therapy. The corresponding estimates in the reference population were similar with odds ratios of 1.80 (1.62-2.01), 1.64 (1.45-1.87), 1.13 (1.05-1.22), and 2.84 (2.21-3.64), respectively. In conclusion, MH is as common in Nigerians as in other populations with older age and higher levels of office BP being major risk factors. A significant proportion of true hypertensive subjects therefore remains undetected based on office BP, which is particularly relevant in sub-Saharan Africa, where hypertension is now a major cause of death.

European Society of Hypertension practice guidelines for ambulatory blood pressure monitoring.

Given the increasing use of ambulatory blood pressure monitoring (ABPM) in both clinical practice and hypertension research, a group of scientists, participating in the European Society of Hypertension Working Group on blood pressure monitoring and cardiovascular variability, in year 2013 published a comprehensive position paper dealing with all aspects of the technique, based on the available scientific evidence for ABPM. The present work represents an updated schematic summary of the most important aspects related to the use of ABPM in daily practice, and is aimed at providing recommendations for proper use of this technique in a clinical setting by both specialists and practicing physicians. The present article details the requirements and the methodological issues to be addressed for using ABPM in clinical practice, The clinical indications for ABPM suggested by the available studies, among which white-coat phenomena, masked hypertension, and nocturnal hypertension, are outlined in detail, and the place of home measurement of blood pressure in relation to ABPM is discussed. The role of ABPM in pharmacological, epidemiological, and clinical research is also briefly mentioned. Finally, the implementation of ABPM in practice is considered in relation to the situation of different countries with regard to the reimbursement and the availability of ABPM in primary care practices, hospital clinics, and pharmacies.

Cardiovascular risk assessment in low-resource settings: a consensus document of the European Society of Hypertension Working Group on Hypertension and Cardiovascular Risk in Low Resource Settings.

The Global Burden of Diseases, Injuries, and Risk Factors Study 2010 confirms ischemic heart disease and stroke as the leading cause of death and that hypertension is the main associated risk factor worldwide. How best to respond to the rising prevalence of hypertension in resource-deprived settings is a topic of ongoing public-health debate and discussion. In low-income and middle-income countries, socioeconomic inequality and cultural factors play a role both in the development of risk factors and in the access to care. In Europe, cultural barriers and poor communication between health systems and migrants may limit migrants from receiving appropriate prevention, diagnosis, and treatment. To use more efficiently resources available and to make treatment cost-effective at the patient level, cardiovascular risk approach is now recommended. In 2011, The European Society of Hypertension established a Working Group on 'Hypertension and Cardiovascular risk in low resource settings', which brought together cardiologists, diabetologists, nephrologists, clinical trialists, epidemiologists, economists, and other stakeholders to review current strategies for cardiovascular risk assessment in population studies in low-income and middle-income countries, their limitations, possible improvements, and future interests in screening programs. This report summarizes current evidence and presents highlights of unmet needs.

Thrombolysis delivery by a regional telestroke network--experience from the U.K. National Health Service.

BACKGROUND: The majority of established telestroke services are based on "hub-and-spoke" models for providing acute clinical assessment and thrombolysis. We report results from the first year of the successful implementation of a locally based telemedicine network, without the need of 1 or more hub hospitals, across a largely rural landscape. METHODS AND RESULTS: Following a successful pilot phase that demonstrated safety and feasibility, the East of England telestroke project was rolled out across 7 regional hospitals, covering an area of 7500 square miles and a population of 5.6 million to enable out-of-hours access to thrombolysis. Between November 2010 and November 2011, 142 telemedicine consultations were recorded out-of-hours. Seventy-four (52.11%) cases received thrombolysis. Median (IQR) onset-to-needle and door-to-needle times were 169 (141.5 to 201.5) minutes and 94 (72 to 113.5) minutes, respectively. Symptomatic hemorrhage rate was 7.3% and stroke mimic rate was 10.6%. CONCLUSIONS: We demonstrate the safety and effectiveness of a horizontal networking approach for stroke telemedicine, which may be applicable to areas where traditional "hub-and-spoke" models may not be geographically feasible.

European Society of Hypertension position paper on ambulatory blood pressure monitoring.

Ambulatory blood pressure monitoring (ABPM) is being used increasingly in both clinical practice and hypertension research. Although there are many guidelines that emphasize the indications for ABPM, there is no comprehensive guideline dealing with all aspects of the technique. It was agreed at a consensus meeting on ABPM in Milan in 2011 that the 34 attendees should prepare a comprehensive position paper on the scientific evidence for ABPM.This position paper considers the historical background, the advantages and limitations of ABPM, the threshold levels for practice, and the cost-effectiveness of the technique. It examines the need for selecting an appropriate device, the accuracy of devices, the additional information and indices that ABPM devices may provide, and the software requirements.At a practical level, the paper details the requirements for using ABPM in clinical practice, editing considerations, the number of measurements required, and the circumstances, such as obesity and arrhythmias, when particular care needs to be taken when using ABPM.The clinical indications for ABPM, among which white-coat phenomena, masked hypertension, and nocturnal hypertension appear to be prominent, are outlined in detail along with special considerations that apply in certain clinical circumstances, such as childhood, the elderly and pregnancy, and in cardiovascular illness, examples being stroke and chronic renal disease, and the place of home measurement of blood pressure in relation to ABPM is appraised.The role of ABPM in research circumstances, such as pharmacological trials and in the prediction of outcome in epidemiological studies is examined and finally the implementation of ABPM in practice is considered in relation to the issue of reimbursement in different countries, the provision of the technique by primary care practices, hospital clinics and pharmacies, and the growing role of registries of ABPM in many countries.

A new solar-powered blood pressure measuring device for low-resource settings.

The management of high blood pressure (BP) is particularly inadequate in low-income countries, where the unavailability of a reliable, durable, and affordable BP-measurement device is a major obstacle to accurate diagnosis. Recognizing this, a World Health Organization committee was established to correct this deficiency by influencing manufacturers to produce a device according to predetermined criteria and to demonstrate the suitability of the device for low resource settings. A device, which fulfilled stipulated criteria in being inexpensive, semiautomated, and solar powered, was validated according to the International Protocol of the European Society of Hypertension; it was then subjected to field testing in 716 subjects from 2 centers in Uganda and 1 in Zambia. The Omron HEM-SOLAR having previously fulfilled accuracy criteria of the International Protocol for both systolic blood pressure (SBP) and diastolic blood pressure (DBP), fulfilled criteria for SBP, but not for DBP, when revalidated. In field testing, average SBPs and DBPs were 120.5 ± 21.6/74.6 ± 13.8 mm Hg and 122.3 ± 21.8/71.2 ± 14.0 mm Hg, respectively, with the auscultatory technique and the Omron HEM-SOLAR, respectively. Between-device agreement in defining SBP was 93.7%. The Omron HEM-SOLAR was favored over the mercury sphygmomanometer by both patients and investigators. In summary, considering the accuracy, robustness, relatively low cost, operational simplicity, and advantages such as solar power, the Omron HEM-SOLAR is likely to be a valuable device for improving BP measurement in low-resource settings with nonphysician health workers.

Recommendations for blood pressure measuring devices for office/clinic use in low resource settings.

This paper, which summarizes the conclusions of a WHO Expert meeting, is aimed at proposing indications to develop technical specifications for an accurate and affordable blood pressure measuring device for office/clinic use in low resource settings. Blood pressure measuring devices to be used in low resource settings should be accurate, affordable, and easily available worldwide. Given the serious inherent inaccuracy of the auscultatory technique, validated and affordable electronic devices, that have the option to select manual readings, seem to be a suitable solution for low resource settings. The agreement on the technical specifications for automated blood pressure measuring devices for office/clinic use in low resource settings included the following features: high accuracy, adoption of electronic transducers and solar batteries for power supply, standard rates of cuff inflation and deflation, adequate cuff size, digital display powered by solar batteries, facilities for adequate calibration, environmental requirements, no need of memory function, resistance to shock and temperature changes, and low cost. Availability of a device with these features should be accompanied by adequate training of health care personnel, who should guarantee implementation of the procedures recommended in recent European and American Guidelines for accurate blood pressure measurement.

Antihypertensive treatment based on blood pressure measurement at home or in the physician's office: a randomized controlled trial.

CONTEXT: Self-measurement of blood pressure is increasingly used in clinical practice, but how it affects the treatment of hypertension requires further study. OBJECTIVE: To compare use of blood pressure (BP) measurements taken in physicians' offices and at home in the treatment of patients with hypertension. DESIGN, SETTING, AND PARTICIPANTS: Blinded randomized controlled trial conducted from March 1997 to April 2002 at 56 primary care practices and 3 hospital-based outpatient clinics in Belgium and 1 specialized hypertension clinic in Dublin, Ireland. Four hundred participants with a diastolic BP (DBP) of 95 mm Hg or more as measured at physicians' offices were enrolled and followed up for 1 year. INTERVENTIONS: Antihypertensive drug treatment was adjusted in a stepwise fashion based on either the self-measured DBP at home (average of 6 measurements per day during 1 week; n = 203) or the average of 3 sitting DBP readings at the physician's office (n = 197). If the DBP guiding treatment was above (>89 mm Hg), at (80-89 mm Hg), or below (<80 mm Hg) target, a physician blinded to randomization intensified antihypertensive treatment, left it unchanged, or reduced it, respectively. MEAN OUTCOME MEASURES: Office and home BP levels, 24-hour ambulatory BP, intensity of drug treatment, electrocardiographic and echocardiographic left ventricular mass, symptoms reported by questionnaire, and costs of treatment. RESULTS: At the end of the study (median follow-up, 350 days; interquartile range, 326-409 days), more home BP than office BP patients had stopped antihypertensive drug treatment (25.6% vs 11.3%; P<.001) with no significant difference in the proportions of patients progressing to multiple-drug treatment (38.7% vs 45.1%; P =.14). The final office, home, and 24-hour ambulatory BP measurements were higher (P<.001) in the home BP group than in the office BP group. The mean baseline-adjusted systolic/diastolic differences between the home and office BP groups averaged 6.8/3.5 mm Hg, 4.9/2.9 mm Hg, and 4.9/2.9 mm Hg, respectively. Left ventricular mass and reported symptoms were similar in the 2 groups. Costs per 100 patients followed up for 1 month were only slightly lower in the home BP group (3875 vs 3522 [4921 dollars vs 4473 dollars]; P =.04). CONCLUSIONS: Adjustment of antihypertensive treatment based on home BP instead of office BP led to less intensive drug treatment and marginally lower costs but also to less BP control, with no differences in general well-being or left ventricular mass. Self-measurement allowed identification of patients with white-coat hypertension. Our findings support a stepwise strategy for the evaluation of BP in which self-measurement and ambulatory monitoring are complementary to conventional office measurement and highlight the need for prospective outcome studies to establish the normal range of home-measured BP.

A longitudinal study of the yield and clinical utility of a specifically designed secondary hypertension investigation protocol.

OBJECTIVE: It has become common practice to use a day-case based approach to identify from the population of hypertensive patients those with an identifiable cause. We aimed to prospectively identify 96 consecutive hypertensive patients undergoing an algorithmic investigation protocol based around two day case hospital attendances. METHODS: The overall diagnostic yield and associated costs were recorded and the patients were observed for a mean of 2.5 years with ambulatory blood pressure (BP) monitoring every three months. RESULTS: A secondary cause of hypertension was identified in 18.1% of patients, three quarters of whom had renovascular disease. There was a fall in blood pressure with time (157/97 vs. 140/85) but this was associated with an increase in the amount of medication required (mean medication score 5.99 vs. 7.65). Improvement in BP occurred irrespective of whether or not a secondary cause was identified. Only 3.2% of patients were cured of their hypertension as a result of enrollment in the protocol. The cost of identifying each case of secondary hypertension was Euro 10, 196. CONCLUSIONS: A comprehensive protocol aimed at identifying secondary hypertension had a low yield, the majority of whom had renovascular disease. In light of recent data illustrating the lack of improvement in BP following dilatation or bypass of atherosclerotic renovascular disease, it is debatable whether searching for it is justifiable.