[Lancet Commission on Hypertension Group position statement on the global improvement of accuracy standards for devices that measure blood pressurePosicionamento do Grupo da Lancet Commission on Hypertension sobre a melhoria global dos padrões de acurácia para aparelhos que medem a pressão arterial]. / 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.

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.

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.

How to find and use validated blood pressure measuring devices.

Clinically validated, automated arm-cuff blood pressure measuring devices (BPMDs) are recommended for BP measurement. However, most BPMDs available for purchase by consumers globally are not properly validated. This is a problem because non-validated BPMDs are less accurate and precise than validated ones, and therefore if used clinically could lead to misdiagnosis and mismanagement of BP. In response to this problem, several validated device lists have been developed, which can be used by clinicians and consumers to identify devices that have passed clinical validation testing. The purpose of this review is to describe the resources that are available for finding validated BPMDs in different world regions, to identify the differences between validated device lists, and describe current gaps and challenges. How to use validated BPMDs properly is also summarised.

Validation of the blood pressure measurement technology used in the Novacor Diasys 3 (DIS-0001-00) upper arm device for ambulatory blood pressure measurement, according to the requirements of the AAMI/ANSI/ISO 81060-2:2013 standard (for both a general study and a cardiac-stress study in adults) and of the European Society of Hypertension International Protocol revision 2010.

OBJECTIVE: The objective of this study was to determine the accuracy of the oscillometric blood pressure measurement technology of the Novacor Diasys 3 (model number DIS-0001-00) blood pressure monitor, intended for ambulatory blood pressure measurement, when used with the recommended Standard (ACC-0213-00), Large (ACC-0214-00) and Paediatric (ACC-0215-00) cuffs. METHODS: The Novacor Diasys 3 (model number DIS-0001-00) was evaluated according to the requirements of the AAMI/ANSI/ISO 81060-2:2013 standard, including an additional cardiac-stress study, a requirement for ambulatory blood pressure measurement devices. It was also validated according to the requirements of the European Society of Hypertension International Protocol revision 2010. The protocol requirements for all thee studies were followed precisely. RESULTS: The Novacor Diasys 3 (model number DIS-0001-00) fulfilled all of the requirements for a pass in each of the three studies. In the primary AAMI/ANSI/ISO 81060-2:2013 study, the Criterion 1 errors were +3.9 mmHg ± 2.9 mmHg for SBP and +3.4 ± 2.5 mmHg for DBP. CONCLUSION: The Novacor Diasys 3 (model number DIS-0001-00), when used with the recommended cuffs, can be recommended for ambulatory blood pressure measurement in the adult population.

Validation of the blood pressure measurement technology used in the Novacor Diasys 3 Plus (DIP-0001-00) upper-arm device for ambulatory blood pressure measurement, according to AAMI/ANSI/ISO 81060-2: 2013, ESH-IP 2010 and MEDDEV 2.7/1.

OBJECTIVE: The objective of this study was to determine the accuracy of the auscultatory and oscillometric blood pressure (BP) measurement technologies of the Novacor Diasys 3 Plus (model number DIP-0001-00) BP monitor, intended for ambulatory BP measurement when used with the recommended Standard Plus (ACC-0210-00), Large Plus (ACC-0211-00) and Paediatric Plus (ACC-0212-00) cuffs. METHODS: The auscultatory measurement technology Novacor Diasys 3 Plus (model number DIP-0001-00) was evaluated according to the requirements of the AAMI/ANSI/ISO 81060-2:2013 standard, including an additional cardiac-stress study, a requirement for ambulatory BP measurement devices. It was also validated according to the requirements of the European Society of Hypertension International Protocol revision 2010. The oscillometric measurement technology was compared to that of the Novacor Diasys 3 (model number DIS-0001-00) according to the equivalence requirements of MEDDEV 2.7/1 rev 4. The protocol requirements for all three studies and the equivalence were followed precisely. RESULTS: The Novacor Diasys 3 Plus (model number DIP-0001-00) fulfilled all of the requirements for a pass in each of the three studies of the auscultatory measurement technology. In the primary AAMI/ANSI/ISO 81060-2:2013 study, the criterion 1 errors were + 3.6 ± 2.7 mmHg for SBP and + 3.0 ± 2.7 mmHg for DBP. It was also proven to be equivalent to the Novacor Diasys 3 (model number DIS-0001-00) with respect to the oscillometric measurement technology CONCLUSION: The Novacor Diasys 3 Plus (model number DIP-0001-00), when used with the recommended cuffs, can be recommended for ambulatory BP measurement in the adult population.

Lancet Commission on Hypertension group position statement on the global improvement of accuracy standards for devices that measure blood pressure.

: 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 3000 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 Organisation 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.

Short-term and long-term repeatability of the morning blood pressure in older patients with isolated systolic hypertension.

OBJECTIVE: Using 24-h ambulatory blood pressure monitoring, we studied the repeatability of the morning blood pressure in older (> or =60 years) patients with isolated systolic hypertension. METHODS: The sleep-through morning surge was the morning blood pressure minus the lowest nighttime blood pressure. The preawake morning surge was the morning blood pressure minus the preawake blood pressure. In addition, we determined the cusum plot height of blood pressure from 04:00 to 10:00 h from a plot of cumulative sums. RESULTS: In 173 patients with repeat recordings within 33 days (median), the short-term repeatability coefficients, expressed as percentages of maximal variation, ranged from 35 to 41% for the daytime and nighttime blood pressures and from 50 to 56% for the night-to-day blood pressure ratios. Short-term repeatability ranged from 52 to 75% for the sleep-through and the preawake morning surge, and from 51 to 62% for the cusum plot height. In 219 patients with repeat recordings within 10 months (median), the corresponding long-term estimates ranged from 45 to 64%, from 69 to 71%, from 76 to 83%, and from 50 to 78%, respectively. In categorical analyses of the short-term repeatability of the sleep-through morning surge and the preawake morning surge, using the 75th percentile as arbitrary cut-off, surging status changed in 28.0 and 26.8% of patients (kappa-statistic < or =0.33). In the long-term interval, these proportions were 32.0 and 32.0%, respectively (kappa-statistic < or =0.20). The kappa-statistic threshold for moderate reproducibility is 0.4. CONCLUSION: The morning surge of blood pressure is poorly reproducible, irrespective of whether it is analysed as continuous or categorical variable.

A Universal Standard for the Validation of Blood Pressure Measuring Devices: Association for the Advancement of Medical Instrumentation/European Society of Hypertension/International Organization for Standardization (AAMI/ESH/ISO) Collaboration Statement.

In the past 30 years, several organizations, such as the US Association for the Advancement of Medical Instrumentation (AAMI), the British Hypertension Society, the European Society of Hypertension (ESH) Working Group on Blood Pressure (BP) Monitoring, and the International Organization for Standardization (ISO), have developed protocols for clinical validation of BP measuring devices. However, it is recognized that science, as well as patients, consumers, and manufacturers, would be best served if all BP measuring devices were assessed for accuracy according to an agreed single validation protocol that had global acceptance. Therefore, an international initiative was taken by the AAMI, ESH, and ISO experts who agreed to develop a universal standard for device validation. This statement presents the key aspects of a validation procedure, which were agreed by the AAMI, ESH, and ISO representatives as the basis for a single universal validation protocol. As soon as the AAMI/ESH/ISO standard is fully developed, this will be regarded as the single universal standard and will replace all other previous standards/protocols.

A universal standard for the validation of blood pressure measuring devices: Association for the Advancement of Medical Instrumentation/European Society of Hypertension/International Organization for Standardization (AAMI/ESH/ISO) Collaboration Statement.

: In the last 30 years, several organizations, such as the US Association for the Advancement of Medical Instrumentation (AAMI), the British Hypertension Society, the European Society of Hypertension (ESH) Working Group on Blood Pressure (BP) Monitoring and the International Organization for Standardization (ISO) have developed protocols for clinical validation of BP measuring devices. However, it is recognized that science, as well as patients, consumers and manufacturers would be best served if all BP measuring devices were assessed for accuracy according to an agreed single validation protocol that had global acceptance. Therefore, an international initiative was taken by AAMI, ESH and ISO experts who agreed to develop a universal standard for device validation. This statement presents the key aspects of a validation procedure, which were agreed by the AAMI, ESH and ISO representatives as the basis for a single universal validation protocol. As soon as the AAMI/ESH/ISO standard is fully developed, this will be regarded as the single universal standard and will replace all other previous standards/protocols.

The dabl Educational Trust device equivalence procedure.

Manufacturers of blood pressure measuring devices that have previously been successfully validated for accuracy may make modifications to a device, which do not affect its measurement accuracy and should not require further validation. In this paper the procedure for manufacturers to declare the equivalence of a modified device with a device that has been validated earlier is described.

State-of-the-market from the dableducational.org website.

Inaccurate blood pressure measurement leads inevitably to the inappropriate diagnosis and treatment of hypertension with resultant disadvantages for patients. Despite the serious consequences of inaccurate measurement of blood pressure the fact is that there are many inaccurate devices in the market and many have not been validated independently for accuracy. To overcome this deficiency, state-of-the-market papers have been published over the past decade. These papers, however, are limited in their availability to the wide range of potential purchasers of blood pressure measuring devices and such papers are often out-of-date by the time of publication. The dableducational website was founded in 2003 to provide regularly updated evidence-based information on blood pressure measuring devices on the internet to all would-be purchasers of blood pressure measuring devices. Since its foundation, the dableducational website has received in excess of 2 million visits; it is used by 1200 organizations in more than 105 countries worldwide, and receives an average of 160,000 visits monthly with a high percentage take down rate. In addition, the website provides a library resource with over 450 papers, and a device equivalence procedure for manufacturers.

High-fidelity digital recording and playback sphygmomanometry system: device description and proof of concept.

OBJECTIVES: This study describes the development of a new digital sphygmocorder (DS-II), which allows the digital recording and playback of the Korotkoff sounds, together with cuff pressure waveform, and its performance in a pilot validation study. MATERIALS AND METHODS: A condenser microphone and stethoscope head detect Korotkoff sounds and an electronic chip, dedicated to audio-signal processing, is used to record high-quality sounds. Systolic and diastolic blood pressure (SBP/DBP) are determined from the recorded signals with an automatic beat detection algorithm that displays the cuff pressure at each beat on the monitor. Recordings of Korotkoff sounds, with the cuff pressure waveforms, and the simultaneous on-site assessments of SBP/DBP were performed during 100 measurements in 10 individuals. The observers reassessed the recorded signals to verify their accuracy and differences were calculated. RESULTS: The features of the high-fidelity DS-II, the technical specifications and the assessment procedures utilizing the playback software are described. Interobserver absolute differences (mean±SD) in measurements were 0.7±1.1/1.3±1.3 mmHg (SBP/DBP) with a mercury sphygmomanometer and 0.3±0.9/0.8±1.2 mmHg with the DS-II. The absolute DS-II mercury sphygmomanometer differences were 1.3±1.9/1.5±1.3 mmHg (SBP/DBP). CONCLUSION: The high-fidelity DS-II device presents satisfactory agreement with simultaneous measurements of blood pressure with a mercury sphygmomanometer. The device will be a valuable methodology for validating new blood pressure measurement technologies and devices.

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)

Twenty-four-hour ambulatory blood pressure in community-dwelling elderly men and women, aged 60-102 years.

OBJECTIVE: To investigate ambulatory blood pressure in elderly people, including 'old elderly' subjects, aged over 80 years. DESIGN: Cross-sectional study of community-dwelling, elderly subjects. METHODS: Subjects were healthy, self-caring, and living independently. Those who were taking medication affecting blood pressure were excluded. Conventional blood pressure was the mean of two measurements. Ambulatory blood pressure monitoring was performed using the SpaceLabs 90207 device. Daytime and night-time blood pressure were defined by fixed clock intervals. RESULTS: Seventy-five 'young elderly', aged 60-79 years, (39 men, 36 women) and 81 'old elderly' aged 80 years and older (37 men, 44 women) underwent 24-h ambulatory blood pressure monitoring. Systolic blood pressure (SBP) was related to age, correlation coefficients between age and SBP were 0.31, 0.25 and 0.31, respectively, for conventional SBP, daytime SBP and night-time SBP (P < 0.01 for all). There was no correlation between age and diastolic blood pressure. Blood pressure levels were similar in men and women. Mean conventional blood pressure, daytime blood pressure and night-time blood pressure were found to be 149/81, 138/82 and 119/69 mmHg, respectively, in the 'young elderly' and 162/82, 147/83, and 133/71 mmHg, respectively, in the 'old elderly (P < 0.01 for SBP). The night : day SBP ratio was significantly higher in the 'old' elderly compared with the 'young' elderly (0.90 versus 0.86, respectively; P < 0.01). CONCLUSIONS: Ambulatory blood pressure levels in healthy, community-dwelling 'old elderly' are higher than those reported for younger adults and reflect the prominent age-related rise in SBP associated with advanced old age. Advanced old age is associated with a diminished nocturnal dip in blood pressure.

Can improved software facilitate the wider use of ambulatory blood pressure measurement in clinical practice?

BACKGROUND: 24-h ambulatory blood pressure measurement (ABPM) is now recognized as being indispensable in the diagnosis and management of hypertension. The technique must, therefore, be made available in primary care, but in doing so it must be recognized that unfamiliarity with the technique may lead to misinterpretation of data. OBJECTIVE: To facilitate the wider application of ABPM, especially in primary care, we examined the features that would facilitate the development of a standardized user-friendly software program for the presentation, analysis and interpretation of data. METHODS AND RESULTS: The following features were considered essential to any software program for ABPM: standardized plots of 24-h profiles; computer interpretation of ABPM data and patterns; a user-friendly one-page report, flexible statistical analysis, and the facility to group data and to export data for audit and research analysis. The dabl ABPM program incorporating these features was introduced into the Blood Pressure Unit, Beaumont Hospital in 2000 and has been used in over 15 000 ABPM recordings. The program is now being used widely in general practice and specialized centres. CONCLUSIONS: It is feasible to design a software program to provide a standardized plotting format for ABPM, a basic analysis of data for day-to-day clinical work, or elaborate analyses for research, and an interpretative report to assist diagnosis and to provide an educational process for doctors and nurses not familiar with the technique.

Validation of the TONOPORT V ambulatory blood pressure monitor according to the European Society of Hypertension International Protocol for Validation of Blood Pressure Measuring Devices in Adults.

BACKGROUND: It is now accepted that blood pressure measuring devices should be subjected to an independent evaluation of their accuracy before they are marketed for clinical use. The results of validation of the TONOPORT V blood pressure monitor for the measurement of ambulatory blood pressure according to the European Society of Hypertension International Protocol for Validation of Blood Pressure Measuring Devices in Adults are presented in this paper. POPULATION: Thirty-three subjects were recruited from among staff and patients at Beaumont Hospital, Dublin, Ireland. METHODS: The TONOPORT V monitor was connected to the Sphygmocorder, an audiovisual system for validation, which records blood pressure on tape and video for later analysis. Nine sequential same-arm measurements between the device and a standard mercury sphygmomanometer were recorded using the Sphygmocorder. RESULTS: In phase 1, the TONOPORT V monitor produced 28 measurements within 5 mmHg, 37 within 10 mmHg and 40 within 15 mmHg for systolic blood pressure (SBP), and 26 within 5 mmHg, 38 within 10 mmHg and 44 within 15 mmHg for diastolic blood pressure (DBP). The mean differences were -2.2 (8.6) [mean (SD)] mmHg for SBP and +0.5 (7.2) mmHg for DBP. The TONOPORT V monitor passed all the criteria for both SBP and DBP. In phase 2.1, the TONOPORT V monitor had 56 measurements within 5 mmHg, 78 within 10 mmHg and 88 within 15 mmHg for SBP, and 60 measurements within 5 mmHg, 83 within 10 mmHg and 97 within 15 mmHg for DBP. The mean differences were -1.4 (8.7) mmHg for SBP and -0.2 (6.8) mmHg for DBP. The TONOPORT V monitor passed the criteria for DBP but failed to meet any of the criteria for SBP. In phase 2.2, 19 subjects had at least two of the differences within 5 mmHg and six subjects had no differences within 5 mmHg for SBP, and 22 subjects had at least two of the differences within 5 mmHg and six subjects no differences within 5 mmHg for DBP. The TONOPORT V monitor failed to meet the criteria for SBP and for DBP. CONCLUSIONS: The TONOPORT V monitor cannot be recommended for clinical use in an adult population because it records SBP inaccurately and because it records DBP inaccurately in an unacceptably high proportion of people.

Validation of the ROSSMAX blood pressure measuring monitor according to the European Society of Hypertension International Protocol for Validation of Blood Pressure Measuring Devices in Adults.

BACKGROUND: It is now accepted that blood pressure measuring devices should be subjected to an independent evaluation of their accuracy before they are marketed for clinical use. The results of validation of the ROSSMAX Blood Pressure Measuring Monitor for self-measurement according to the European Society of Hypertension International Protocol for Validation of Blood Pressure Measuring Devices in Adults are presented in this paper. POPULATION: Thirty-three subjects were recruited from among staff and patients at Beaumont Hospital, Dublin, Ireland. METHODS: The ROSSMAX monitor was connected to the Sphygmocorder, an audiovisual system for validation, which records blood pressure on tape and video for later analysis. Nine sequential same-arm measurements between the device and a standard mercury sphygmomanometer were recorded using the Sphygmocorder. RESULTS: In phase 1, the ROSSMAX monitor produced 21 measurements within 5 mmHg, 31 within 10 mmHg and 38 within 15 mmHg for systolic blood pressure (SBP), and 36 within 5 mmHg, 43 within 10 mmHg and 45 within 15 mmHg for diastolic blood pressure (DBP). The mean differences were -5.6 (10.2) [mean (SD)] mmHg for SBP and -0.5 (4.5) mmHg for DBP. The ROSSMAX monitor failed to meet any of the criteria for SBP but comfortably passed all of the criteria for DBP. In phase 2.1, the ROSSMAX monitor had 51 measurements within 5 mmHg, 73 within 10 mmHg and 86 within 15 mmHg for SBP, and 71 measurements within 5 mmHg, 93 within 10 mmHg and 98 within 15 mmHg for DBP. The mean differences were -4.5. (9.5) mmHg for SBP and -1.8 (5.0) mmHg for DBP. The ROSSMAX monitor failed to meet any of the criteria for SBP but comfortably passed all of the criteria for DBP. In phase 2.2, 16 subjects had at least two of the differences lying within 5 mmHg and 10 subjects had no differences within 5 mmHg for SBP; 26 subjects had at least two of the differences falling within 5 mmHg and three subjects no differences within 5 mmHg for DBP. The ROSSMAX monitor failed to meet the criteria for SBP but passed the criteria for DBP. CONCLUSIONS: The ROSSMAX monitor cannot be recommended for clinical use in an adult population because it records SBP inaccurately.

Ambulatory blood pressure measurement as a predictor of outcome in an Irish population: methodology for ascertaining mortality outcome.

BACKGROUND: Ambulatory blood pressure monitoring (ABPM) has proven to be a superior predictor of morbid events when compared to clinic or office blood pressure measurement (CBPM). The purpose of this study was to evaluate the predictive value of ABPM in a sample of 14 414 people referred for management of cardiovascular risk. METHODS: In this paper we describe the methodology required to examine mortality outcome in the absence of a national unique identifier. RESULTS: Using a computerized database of deaths we were able to establish that 1348 people had died by the end of the follow-up period (30 September 2002). Sixty-four percent of deaths were cardiovascular and in 207 subjects who had post-mortem examinations, 78% were cardiovascular. CONCLUSIONS: The accurate identification of the cause of death in a large population will allow comparison of the relative predictive power of APBM and CBPM in an Irish population.

Limitations of current validation protocols for home blood pressure monitors for individual patients.

BACKGROUND: Automatic blood pressure monitoring conducted at home is increasingly used in the diagnosis and management of hypertension. We assessed the adequacy of existing British Hypertension Society (BHS) and Association for the Advancement of Medical Instrumentation (AAMI) validation standards for automatic blood pressure monitoring devices. SUBJECT AND METHODS: A theoretical study and an empirical test are presented to estimate the proportion of persons for whom a blood pressure monitor validated according to existing BHS and AAMI standards would be inaccurate. RESULTS: The results suggest that a major limitation of both protocols is the lack of attention given to the number of individual patients for whom a monitor may be inaccurate. A blood pressure monitor that meets the AAMI and BHS validation criteria may report blood pressures in error by more than 5 mmHg for more than half of the people. CONCLUSIONS: A validation standard that does not take account of the person-effects on error will lead to a substantial proportion of persons using self-monitors that are systematically inaccurate for that person.

Impact of applying the more stringent validation criteria of the revised European Society of Hypertension International Protocol 2010 on earlier validation studies.

OBJECTIVE: Since 2002 when the European Society of Hypertension International Protocol (ESH-IP) was published it has become the preferred protocol for validating blood pressure monitors worldwide. In 2010, a revised version of the ESH-IP with more stringent criteria was published. This study assesses the impact of applying the revised ESH-IP criteria. METHODS: A systematic literature review of ESH-IP studies reported between 2002 and 2010 was conducted. The impact of applying the ESH-IP 2010 criteria retrospectively on the data reported in these studies was investigated. The performance of the oscillometric devices in the last decade was also investigated on the basis of the ESH-IP criteria. RESULTS: Among 119 published studies, 112 with sufficient data were analyzed. According to ESH-IP 2002, the test device failed in 19 studies, whereas by applying the ESH-IP 2010 criteria in 28 additional studies increased the failure rate from 17 to 42%. Of these 28 studies, in 20 (71%) the test device failed at part 1 (accuracy per measurement) and in 22 (79%) at part 2 (accuracy per subject). Most of the failures involved the '5 mmHg or less' criterion. In the last decade there has been a consistent trend toward improved performance of oscillometric devices assessed on the basis of the ESH-IP criteria. CONCLUSION: This retrospective analysis shows that the stricter revised ESH-IP 2010 criteria will noticeably increase the failure rate of devices being validated. Oscillometric devices are becoming more accurate, and the revised ESH-IP by acknowledging this trend will allow more accurate devices to enter the market.

Computerized reporting improves the clinical use of ambulatory blood pressure measurement.

BACKGROUND: Ambulatory blood pressure measurement (ABPM) is being used increasingly in clinical practice. One previous study has shown that there can be considerable variance between expert observers in the interpretation of ABPM data. The purpose of this study was to show whether computer-generated reports with the dablABPM system would provide more consistency in the interpretation of data than reports from expert observers. METHODS: Twenty-six international experts in hypertension were invited to participate and 17 agreed to do so. Twelve ABPMs generated by the Spacelabs device that were considered representative of the patterns likely to be seen in practice were sent to each participant for reporting. The corresponding dabl reports with an automatic interpretation were generated according to the European Society of Hypertension guideline for comparison with the observer reports. Each of the observer-interpreted Spacelabs reports for the 12 ABPM patterns were coded, analysed and compared with the automatically interpreted dablABPM reports. Both sets of data were analysed for interobserver variability, observer v dablABPM consistency and the time taken for observer reportage. The main analysis determined issues of definite disagreement, namely the presence or absence of nocturnal dipping. Further analysis determined the presence or absence of white-coat phenomena and the severity of hypertension. RESULTS: Incorrect diagnoses were made in 13 instances. White-coat hypertension and white-coat effect, although obvious in many instances, were not identified in five ABPMs; the severity of hypertension was not reported in four ABPMs; the severity of nocturnal hypertension was not diagnosed in one ABPM by nine experts and isolated diastolic hypertension was not identified by six experts in two ABPMs. CONCLUSION: This study provides evidence to show that observer variance in reporting ABPMs is common even among experts and that computer-generated interpretative reports of ABPM data improve the diagnostic decisions based on the data generated by 24-h blood pressure recording.