Early morning surge and dipping status of blood pressure: are these of predictive value for silent myocardial ischemia?

To investigate the predictive value of morning surge (MS) and dipping status of blood pressure (BP) for ST-segment depression (ST depression) in hypertensive persons, the combined 24-hour ambulatory BP measurement and Holter electrocardiographic recordings of 344 patients (132 women and 212 men, 60+/-12 years) were analyzed. The morning BP surge was calculated as mean systolic BP during the 2 hours after awaking minus the mean systolic BP during the 1 hour that included the lowest sleep BP. Depending on the percentage decrease in systolic BP at night, patients were subdivided into extreme dippers, dippers, nondippers, and risers. ST depression was defined as horizontal or descending ST depression of 1 mm of 1 minute duration and a 1-minute interval after the previous episode or 24-hour mean ST-segment value <-0.1 mV. ST depression was observed in 76 (22.1%) of 344 patients. The mean MS in patients with ST depression was with 25+/-15 mm Hg and not significantly different when compared with patients without ST depression (26+/-15 mm Hg). The prevalence of ST depression was not significantly different in dippers, extreme dippers, nondippers, and risers (20%, 23.5%, 23%, and 25.5%, respectively). Systolic and diastolic BP values during ST depression were significantly higher in the morning as compared with ST depression in the evening (149/84 mm Hg vs 138/78 mm Hg, P<.05). In the present study, MS and dipping status of BP were not associated with ST depression. ST depression was, however, characterized by significantly higher BP peaks in the early morning hours.

Reproducibility of wrist home blood pressure measurement with position sensor and automatic data storage.

BACKGROUND: Wrist blood pressure (BP) devices have physiological limits with regards to accuracy, therefore they were not preferred for home BP monitoring. However some wrist devices have been successfully validated using established validation protocols. Therefore this study assessed the reproducibility of wrist home BP measurement with position sensor and automatic data storage. METHODS: To compare the reproducibility of three different(BP) measurement methods: 1) office BP, 2) home BP (Omron wrist device HEM- 637 IT with position sensor), 3) 24-hour ambulatory BP(24-h ABPM) (ABPM-04, Meditech, Hun)conventional sphygmomanometric office BP was measured on study days 1 and 7, 24-h ABPM on study days 7 and 14 and home BP between study days 1 and 7 and between study days 8 and 14 in 69 hypertensive and 28 normotensive subjects. The correlation coefficient of each BP measurement method with echocardiographic left ventricular mass index was analyzed. The schedule of home readings was performed according to recently published European Society of Hypertension (ESH)- guidelines. RESULTS: The reproducibility of home BP measurement analyzed by the standard deviation as well as the squared differences of mean individual differences between the respective BP measurements was significantly higher than the reproducibility of office BP (p < 0.001 for systolic and diastolic BP) and the reproducibility of 24-h ABPM (p < 0.001 systolic BP, p = 0.127 diastolic BP). The reproducibility of systolic and diastolic office versus 24-h ABPM was not significantly different (p = 0.80 systolic BP, p = 0.1 diastolic BP). The correlation coefficient of 24-h ABMP (r = 0.52) with left ventricular mass index was significantly higher than with office BP (r = 0.31). The difference between 24-h ABPM and home BP (r = 0.46) was not significant. CONCLUSION: The short-term reproducibility of home BP measurement with the Omron HEM-637 IT wrist device was superior to the reproducibility of office BP and 24- h ABPM measurement. Furthermore, home BP with the wrist device showed similar correlations to targeted organ damage as recently reported for upper arm devices. Although wrist devices have to be used cautious and with defined limitations, the use of validated devices with position sensor according to recently recommended measurement schedules might have the potential to be used for therapy monitoring.

Management of hypertension with fixed dose combinations of candesartan cilexetil and hydrochlorothiazide: patient perspectives and clinical utility.

Hypertension treatment and control is largely unsatisfactory when guideline-defined blood pressure goal achievement and maintenance are considered. Patient- and physician-related factors leading to non-adherence interfere in this respect with the efficacy, tolerability, and convenient use of pharmacological treatment options. Blockers of the renin-angiotensin system (RAS) are an important component of antihypertensive combination therapy. Thiazide-type diuretics are usually added to increase the blood pressure lowering efficacy. Fixed drug-drug combinations of both principles like candesartan/hydrochlorothiazide (HCTZ) are highly effective in lowering blood pressure while providing improved compliance, a good tolerability, and largely neutral metabolic profile. Comparative studies with losartan/HCTZ have consistently shown a higher clinical efficacy with the candesartan/HCTZ combination. Data on the reduction of cardiovascular endpoints with fixed dose combinations of antihypertensive drugs are however scarce, as are the data for candesartan/HCTZ. But many trials have tested candesartan versus a non-RAS blocking comparator based on a standard therapy including thiazide diuretics. The indications tested were heart failure and stroke and particular emphasis was put on elderly patients or those with diabetes. In patients with heart failure, for example, the fixed dose combination might be applied in patients in whom individual titration resulted in a dose of 32 mg candesartan and 25 mg HCTZ which can then be combined into one tablet to increase compliance with treatment. Also in patients with stroke the fixed dose combination might be used in patients in whom maintenance therapy with both components is considered. Taken together candesartan/HCTZ assist both physicians and patients in achieving long-term blood pressure goal achievement and maintenance.

A new oscillometric method for assessment of arterial stiffness: comparison with tonometric and piezo-electronic methods.

INTRODUCTION: Pulse wave velocity (PWV) and augmentation index (AIx) are parameters of arterial stiffness and wave reflection. PWV and AIx are strong indicators for cardiovascular risk and are used increasingly in clinical practice. Previous systems for assessment of PWV and AIx are investigator dependent and time consuming. The aim of this study was to validate the new oscillometric method (Arteriograph) for determining PWV and AIx by comparing it to two clinically validated, broadly accepted tonometric and piezo-electronic systems (SphygmoCor and Complior). DESIGN AND METHOD: PWV and AIx were measured up to five times in 51 patients with the SphygmoCor, Complior and Arteriograph. In 35 patients, the measurements were repeated after 1 week in a second session using the same protocol. RESULTS: The correlations of the PWV as assessed with the Arteriograph with the values obtained using the SphygmoCor (r = 0.67, P < 0.001) and the Complior (r = 0.69, P < 0.001) were highly significant. Variability and reproducibility for PWV were best for the Arteriograph, followed by Complior and SphygmoCor. AIx (SphygmoCor versus Arteriograph) were very closely correlated (r = 0.92, P < 0.001). PERSPECTIVES: The Arteriograph is a new, easy-to-use and time-effective method for assessing arterial stiffness and wave reflection.

Inflammatory responses after endothelin B (ETB) receptor activation in human monocytes: new evidence for beneficial anti-inflammatory potency of ETB-receptor antagonism.

Endothelin (ET) stimulates potent ETA/ETB receptors important in the pathogenesis of pulmonary arterial hypertension (PAH) and fibrosis. Though therapy with ET-receptor antagonists is well established uncertainty exists whether selective ETA or dual ETA/ETB-receptor antagonism is superior in PAH. The objective of this study was to further elucidate the pro-inflammatory effects of ET-1 on ETB receptors in cultured human monocytes (10(5)/20 h) compared with non-specific stimulation with LPS in vitro and to define the antagonizing effects of bosentan, a dual ETA/ETB-receptor antagonist, on inflammatory mediator production. We further hypothesized that ETB-receptor antagonism reduces the requirement of PGE2 to control inflammatory mediator production. Activation of the monocyte ETB subtype by ET (1 ng/ml) concentration-dependently stimulated TNF-alpha (744%) >PGE2 (570%) > IL-1 beta (112%) and had no effect on 5-lipoxygenase metabolism. Compared with ET a different profile of IL-1 beta >TNF-alpha >PGE2 was induced by LPS. ETB-receptor antagonism attenuated ET- and LPS-responses in monocytes, in particular of TNF-alpha and PGE2 to a similar extend (40%) that were only demonstrable following LPS at therapeutic plasma concentrations of bosentan and had no effect on IL-1 beta. Inhibition of ETB receptors in LPS-stimulated monocytes by bosentan was responded with suppression of PGE2 and increased production of leukotrienes indicating strong effects in the cyclooxygenase pathway that is known to control cellular ET transcription. These data suggest an important signaling pathway between ET-induced cytokine production following ETB-receptor activation with no further control of ET transcription by PGE2 required following ETB receptor antagonism. Therefore, in states of inflammation increased ETB-receptor expression and activation mediated by elevated ET concentrations may be an underestimated mechanism, which warrants the application of combined ETA/ETB-receptor antagonists.

ST segment depression in hypertensive patients: a comparison of exercise test versus Holter ECG.

INTRODUCTION: This study compared ST segment depression (ST depression) during cycle ergometry (ergometry) versus simultaneous 24-hour ambulatory blood pressure measurement and electrocardiogram recording (24-h ABPM/ECG) during everyday life. METHODS: In a German multicenter study, ergometry and 24-h ABPM/ECG records of 239 hypertensive patients were retrospectively analyzed. ST depression was defined as an ST segment depression (1 mm limb or chest recordings V1 to V6) in an incremental cycle ergometry, or 1 mm in the 24-h ABPM/ECG recording under everyday conditions. Blood pressure parameters at the onset of ST depression in the context of the respective method were compared. RESULTS: 18 patients had ST depression only in ergometry (group B), 23 had ST depression only during 24-h ABPM/ECG monitoring (group C) and 28 patients had ST depression with both methods (group D). Group A had no ST depression with any method. In group D, at the onset of ST depression with 24-h ABPM/ECG investigation, all parameters except diastolic blood pressure were significantly lower compared with the corresponding parameters at the onset of ST depression with ergometry (systolic blood pressure: 148 +/- 19 vers 188 +/- 35 mmHg, p < 0.001; heart rate: 93 +/- 12 vs 120 +/- 21 beat/min, p < 0.0001; double product: 13,714 +/- 2315 vs 22,992 +/- 3,985 mmHg/min), p < 0.0001). CONCLUSION: ST depressions during everyday life detected by 24-h ABPM/ECG are characterized by a substantially lower triggering threshold for blood pressure level parameters compared with ergometry. The two methods detecting ischemia do not replace but complement each other.

Relationship between the frequency of blood pressure self-measurement and blood pressure reduction with antihypertensive therapy : results of the OLMETEL (OLMEsartan TELemonitoring blood pressure) study.

OBJECTIVES: This subanalysis of the OLMETEL (OLMEsartan TELemonitoring blood pressure) study in patients with essential hypertension assessed the relationship between the frequency of blood pressure self-measurement (BPSM) and the response to blood pressure (BP)-lowering therapy with olmesartan medoxomil, and the number of BP readings per week necessary to detect a mean systolic or diastolic BP reduction > or =5mm Hg. METHODS: A total of 53 patients with essential hypertension received treatment with olmesartan medoxomil 10, 20 or 40 mg daily for 12 weeks. BPSM was performed for the first 9 weeks using a TensioPhone TP2 device. Patients were instructed to measure BP at least twice daily (morning and evening). RESULTS: After the first 9 weeks of the 12-week treatment period, the extent of BP reduction correlated with the number of BPSMs. Systolic/diastolic BP reductions in patients with a 100% adherence to at least two BP measurements daily were -16.6/-8.0mm Hg compared with -0.2/-3.3mm Hg in patients with only a 75% adherence to at least one BP measurement daily. Obtaining five home BP readings per week resulted in a sensitivity of 94.8% and a specificity of 90.0% to detect a BP reduction of > or =5mm Hg. CONCLUSION: Patients adhering to the instructions for BPSM (at least two measurements daily) had a better response to antihypertensive treatment with olmesartan medoxomil. Whether BPSM per se resulted in an improved adherence to therapy or whether the number of recordings was an indicator of already existing adherence remains to be determined. Obtaining at least five home BP readings per week was identified as the threshold for correctly predicting response to olmesartan medoxomil treatment.

New evidence of H1-receptor independent COX-2 inhibition by fexofenadine HCl in vitro.

BACKGROUND/AIMS: Fexofenadine HCl (FEX) has previously been shown to have anti-inflammatory properties in relieving nasal congestion in allergic rhinitis. The objective of this study was to further elucidate the mechanism of action behind the anti-inflammatory properties of FEX in addition to its H(1)-receptor antagonism. METHODS: The effects of two antihistamines, FEX and loratadine (LOR), were investigated on cyclooxygenase (COX)-1 and -2 enzymes in vitro. FEX (10(-9)-10(-3) mol/l) and LOR (10(-9)-10(-4) mol/l) were incubated with arachidonic acid in a COX screening assay with either ovine COX-1 or COX-2 or human COX-2. COX-2 enzyme inhibitory activity for the antihistamines was compared with the known selective COX-2 inhibitor DuP-679. RESULTS: High concentrations of FEX (10(-3) mol/l) significantly inhibited arachidonic acid-mediated ovine COX-1 activity, but low concentrations had no effect. Low concentrations of FEX (10(-8) mol/l) inhibited ovine COX-2 activity, and this inhibition decreased with increasing concentrations. The inhibition of COX-2 activity by FEX was similar to that seen with the selective COX-2 inhibitor, DuP-679. Conversely, LOR inhibited COX-1 activity at low concentrations (10(-8) mol/l), but had little inhibitory effect on COX-1 at high concentrations. LOR (10(-5) mol/l) markedly stimulated COX-2 activity. CONCLUSION: FEX showed selective arachidonic acid-mediated COX-2 inhibitory enzyme activity, which differed markedly from the COX inhibitory enzyme activity of LOR. This selective COX-2 inhibitor activity by FEX may contribute to its anti-inflammatory properties in relieving nasal congestion in allergic rhinitis.

Management of patients with uncontrolled arterial hypertension--the role of electronic compliance monitoring, 24-h ambulatory blood pressure monitoring and Candesartan/HCTZ.

BACKGROUND: Incomplete drug regimen compliance (DRC) and white-coat hypertension are two of several possible causes of uncontrolled hypertension. Therefore the aim of the present study was to compare DRC in hypertensives treated with combination therapy whose blood pressures (BP) were controlled vers. uncontrolled after 4 weeks of self-monitored BP measurement. To observe the consequences in uncontrolled patients of switching one drug of the combination therapy to candesartan/HCTZ (16 mg/12.5 mg) with and without a compliance intervention program. METHODS: Self-and ambulatory-monitoring of BP were done with upper arm oscillometric devices. Patients' dosing histories were compiled electronically (MEMS, AARDEX). Patients with office blood pressure (OBP) >140/90 mmHg despite combination therapy were begun on MEMS monitoring and self BP measurement for 4 weeks of run-in. Of 62 such patients, 18 (29%) patients were normotensive according to self BP measurement and ambulatory BP measurement at 4 weeks (Group A); in the remaining 44 still uncontrolled patients, candesartan/HCTZ was substituted for one of the combination therapy drugs, with half these patients receiving passive compliance monitoring (B) and half a DRC intervention program (C). All groups were then followed for 8 weeks. RESULTS: DRC before week 4 was significantly higher in A than in the uncontrolled patients (B&C). DRC was stable during run-in A, but declined in B and C. DRC after week 4 was not different in the three groups and stayed constant over time. DRC during weekends was lower than during weekdays in all groups. In group A no significant change in blood pressure was observed with all three methods of BP measurements. In groups B and C significant reductions of systolic and diastolic BP were observed for ABPM and SBPM. After the change to candesartan/HCTZ in B&C ambulatory 24-h-BP (ABPM) was normalized in 39% of patients. CONCLUSION: Normalization of BP was associated with superior drug regimen compliance in previously uncontrolled patients treated with a combination drug regimen. Switching still-uncontrolled patients to candesartan/HCTZ significantly improved BP control and stabilized a declining DRC.

Pulse wave velocity is increased in patients with transient myocardial ischemia.

OBJECTIVE: We have recently shown that mean pulse pressure is higher in patients with transient myocardial ischemia. Pulse pressure elevation might be an important consequence of increased arterial stiffness. The aim of this study was to prove if arterial stiffness is changed in patients with transient myocardial ischemia who bear a high cardiovascular risk. Additionally we investigated whether arterial stiffness or wave reflection is the best indicator for transient myocardial ischemia. Aortic pulse wave velocity (PWV) is a measure of arterial stiffness, and augmentation index (AIx) an indication of arterial wave reflection. Both are indicators for cardiovascular risk. METHODS: PWV (carotid-femoral) and AIx (SphygmoCor) were assessed in 74 hypertensive patients. Transient myocardial ischemia was detected using an ST-triggered 24-h ambulatory blood pressure monitoring device. RESULTS: ST-segment depressions were recorded in 30 of 74 patients. There were no significant differences with regard to age, mean arterial pressure, systolic blood pressure, diastolic blood pressure or heart rate. PWV was seen to be higher in patients with transient myocardial ischemia (10.6 versus 9.5 m/s, P = 0.036). There was no significant difference in AIx between the two groups. PWV (r = 0.36, P = 0.002) but not AIx correlated with pulse pressure. CONCLUSIONS: PWV is higher in hypertensive individuals (age > 60 years) with transient myocardial ischemia, suggesting that PWV is an indicator of increased cardiovascular risk. Although AIx is known to be associated with several cardiovascular diseases, it was not seen to be associated with silent myocardial ischemia. Our results suggest that the clinical significance of parameters of arterial stiffness and arterial wave reflection change with age, with a higher clinical importance of PWV indicated in patients over the age of 60.

Myocardial ischemia during everyday life in patients with arterial hypertension: prevalence, risk factors, triggering mechanism and circadian variability.

INTRODUCTION: The objective of the present study was to investigate the prevalence, the risk factors, the hemodynamic triggering mechanisms, the circadian variability of ST segment depression (ST depression) and the effect of day and night fall in blood pressure on the prevalence of ST depression in hypertensive patients. MATERIALS AND METHODS: In a multicentric study in Germany, 1,244 CardioTens registrations (combined 24-h ambulatory blood pressure measurement/electrocardiography with ST segment triggering; Meditech, Budapest, Hungary) from patients with arterial hypertension were consecutively monitored and evaluated centrally at the University of Bonn. Inclusion criterion was treated or untreated arterial hypertension. The ST segment was measured in accordance with the "1 : 1 : 1 rule" (horizontal or descending ST depression by 1 mm, 1 min duration, 1 min interval from the previous episode). RESULTS: ST segment depression was observed in 250 (20.1%) patients; 90.3% of the transient ST-segment depression was silent (without angina pectoris). Ambulatory 24-h blood pressure measurement, but not office-based blood pressure measurement, was predictive for the occurrence of ST-segment depression. Risk factors for ST-segment depression were the Sokolow index > or =3.5 mV, smoking status, severity of coronary heart disease, use of diuretics, reduced left ventricular function, pulse pressure > or =60 mmHg and increase of double product (1,000 mmHg/min). A significant rise of the systolic/diastolic blood pressure (+8+ or -18/+7+ or -10 mmHg), of the heart rate (+12+ or -13/min) and of the double product (+2,471+ or -2,517 mmHg/min) was found during the transient ST depression as compared with the corresponding 24-h ambulatory blood pressure measurement mean values (P<0.0001 for all parameters specified). In most intermittent ST depressions, a rise of the double product was seen (n=789 episodes), and in the remaining 239 ST depressions, a fall of the double product was observed. ST depressions with fall of the double product showed a circadian distribution with a peak in the late evening. ST depression accompanied by a rise in double product showed two peaks (one in the early morning and one in the late evening). The prevalence of ST depression was significantly higher (28.6%) in extreme dippers than in dippers (18.2%), risers (21.8%) and non-dippers (19.6%). CONCLUSIONS: ST depressions have a high prevalence of 20.1% in hypertensive patients. Clinical predictors for the occurrence of ST-segment depression were classical risk factors and cardiac target organ damage. Office-based blood pressure measurement was not a useful measuring tool for forecasting the likelihood of ST-segment depression. ST depressions were triggered inter alia by variations of blood pressure and the heart rate. The circadian variability of the ST depressions is crucially affected by the pressure double product characteristics on which the ST depression is based.

Telemonitoring of blood pressure self measurement in the OLMETEL study.

OBJECTIVE: To investigate the feasibility of blood pressure (BP) telemonitoring in previous uncontrolled hypertensives treated with olmesartan medoxomil in a clinical practice setting. METHODS: Patients (n = 53) with untreated, uncontrolled or insufficiently treated hypertension were selected by physicians to receive olmesartan medoxomil 10-40 mg/day for 12 weeks. Office BP values were determined by a physician at baseline and after 12 weeks' treatment; BP self-measurement (BPSM) was conducted throughout the 12-week treatment period using a TensioPhone TP2 telemonitoring device; BP values were stored and automatically downloaded to a remote service centre via standard telephone lines. RESULTS: Olmesartan medoxomil produced statistically significant reductions from baseline in both systolic and diastolic office BP and BPSM values. In contrast to office BP, telemonitoring of BPSM allowed the early identification of responders (e.g., after 2-3 weeks' treatment). Blood pressure reduction with olmesartan medoxomil was greater for office BP than for BPSM values. Normalization of BP was achieved in 64.2% of the patients using office BP measurement compared with 36.4% using BPSM. Blood pressure self-measurement showed no significant difference between morning and evening BP measurements or between the morning : evening BP ratio at baseline and after nine weeks of olmesartan medoxomil treatment. Compliance and tolerability were good or very good in most patients. CONCLUSION: In a 'real-life' clinical practice setting, telemonitoring of BPSM was an effective technique that was partially affected by patient non-compliance. Olmesartan medoxomil provided effective and reliable BP-lowering, which was maintained throughout the 24-hour period.

Significance of blood pressure self-measurement as compared with office blood pressure measurement and ambulatory 24-hour blood pressure measurement in pharmacological studies.

With the increasing use of blood pressure self-measurement in pharmacological studies, the question arises as to whether this method can replace office blood pressure measurement or ambulatory 24-h blood pressure measurement for testing and comparing the efficacy of antihypertensives. Ambulatory 24-h blood pressure measurement or self-measurement available for analysis can be obtained in 70 to 90% of patients. Self-measurement shows a better correlation with the prognostically relevant ambulatory 24-h blood pressure measurement than office blood pressure measurement for appraising the antihypertensive effect. Although similar antihypertensive effects were found for ambulatory 24-h blood pressure measurement and self-measurement in the group comparison, substantial discrepancies can be observed in the individual patient owing to the different nature of these two methods of measurement. Both ambulatory 24-h blood pressure measurement and self-measurement are superior to office blood pressure measurement in terms of their reproducibility. This increases the sensitivity of clinical studies and reduces the number of cases required. Owing to the white-coat effect, variable compliance and drug holidays and their effects on the efficacy of antihypertensive medication are not detected by office blood pressure measurement and ambulatory 24-h blood pressure measurement. Self-measurement detects drug holidays, which are reflected in an increase of the blood pressure measurement values, and per se promotes compliance. Self-measurements and ambulatory 24-h measurements in pharmacological studies must be regarded as complementary, so that it is appropriate to use both methods whenever possible. Data management, data analysis and monitoring in pharmacological studies are facilitated by instruments with automatic data storage which allows telemonitoring.

ST-segment depression in hypertensive patients is linked to elevations in blood pressure, pulse pressure and double product by 24-h Cardiotens monitoring.

BACKGROUND: Various statements are made concerning peaks of heart rate (HR), blood pressure (BP) and double product (product of HR and systolic BP) as triggers for ST-segment depression. The aim of the present study was to identify determinants of ST-segment depression with a new ambulatory device for simultaneous 24-h electrocardiogram (ECG) and BP monitoring. METHODS: A total of 63 treated patients (63 +/- 9 years, 33 women and 30 men) with arterial hypertension and ischemic heart disease were studied with a new ambulatory 24-h BP measurement (ABPM) device evaluated according to the BHS protocol (Cardiotens, Meditech, Hungary). This device allows simultaneous ST-segment analysis with extra BP recordings triggered by episodes of ST-segment depression. RESULTS: ST-segment (Holter ECG) depression (> 1 mm and > 60 s) was demonstrated in 26 patients with a mean duration of 4.95 +/- 2.6 min and a peak in the early morning hours. All ST-segment depressions were silent and occurred during a significant increase of BP (15 +/- 11 mmHg systolic and 10 +/- 5 mmHg diastolic, compared with the mean ABPM values) and a significant increase of the double product from 10 921 +/- 2 395 (24-h mean) to 14 515 +/- 2329 (during ST-depression). The recorded systolic and diastolic BP (SBP, DBP) values from the pre ST-event were significant higher compared with 24-h values (153 +/- 19 versus 145 +/- 22 mmHg systolic, 83 +/- 12 versus 78 +/- 14 diastolic). The mean pulse pressure (PP) value in the group with ST-depression was significantly higher than in the group without ST changes (69 +/- 16 versus 58 +/- 10 mmHg; P < 0.005). A total of 73% of patients with ST-events compared with 35% without ST-events showed a PP >or= 60 mmHg (P = 0.025). CONCLUSION: Simultaneous ABPM and ST-segment analysis identifies episodes of silent myocardial ischemia during increases of BP and HR. Hypertensive patients with ischemic heart disease and ST events show higher mean pulse pressure values than are observed in patients without events. A PP of >or= 60 mmHg is linked to an increased risk of silent myocardial ischemias.

Simultaneous recording of blood pressure and ST-segment with combined, triggered ambulatory 24-h devices.

Silent myocardial ischemia is defined as an ischemic episode without chest pain but with transient ST abnormalities during stress testing or Holter monitoring. With Holter monitoring the prevalence of silent myocardial ischemia in hypertensive patients without coronary artery disease is between 25% and 73%. Simultaneous recording of ambulatory 24-h ECG and 24-h ambulatory blood pressure measurements (ABPM) with the option of additional ST-triggered blood pressure measurement is useful to detect silent ischemia and triggers of silent ischaemia. It is surprising that only a few combined 24-h Holter/ABPM devices are on the market, and in turn only three devices allow additional triggered blood pressure measurements. The paper provides an overview of studies investigating hypertensive patients with Holter monitoring for the detection of ST segment depression indicating myocardial ischaemia. Furthermore, requirements for combined devices allowing simultaneous ambulatory 24-h ECG and ABPM are defined.

Evaluation of the performance of a wrist blood pressure measuring device with a position sensor compared to ambulatory 24-hour blood pressure measurements.

This randomized, single-center, open, within-subject study evaluated the performance of the Braun PrecisionSensor 2000 blood pressure (BP) measurement wrist device (BP 2000, Braun GmbH, Germany) with and without the position sensor, and compared the results with data obtained from 24-h ambulatory BP measurement (ABPM, A&D TM 2430). In a crossover design, 43 subjects performed BP measurements with the BP 2000 during two 7-day periods, one with the position sensor and the other without the position sensor. The correlation coefficients between all wrist self-measurements and ABPM were 0.73 for systolic and 0.65 for diastolic BP (with position sensor) compared to 0.70 and 0.60 for readings without position sensor, respectively. The categorization of subjects as normotensive or hypertensive, using the wrist device in subjects without specific training, achieved a correct classification of 84% (with position sensor) and 81% (without position sensor) in comparison to ABPM. When the measurements were performed in the clinic by an experienced observer, the correct classification was 79% in comparison to ABPM. The crossover study design did not show any significant variation between the two devices with regard to reproducibility of readings at the wrist. In conclusion, self-BP measurements with BP 2000, by untrained subjects, produced results consistent with those found recently with self-BP measurements with upper arm devices, when both data sets are compared with ABPM. The rates of false classification of normotension/hypertension with the wrist device were small and at least as reliable as office measurements.