Day-by-Day Blood Pressure Variability in the Subacute Stage of Ischemic Stroke and Long-Term Recurrence.

BACKGROUND AND PURPOSE: This study aimed to determine whether variability of day-by-day blood pressure (BP) during the subacute stage of acute ischemic stroke is predictive of long-term stroke recurrence. METHODS: We analyzed 7665 patients (mean±SD age: 72.9±13.1 years; women: 42.4%) hospitalized for first-ever ischemic stroke in 7 stroke centers in Fukuoka, Japan, from June 2007 to November 2018. BP was measured daily during the subacute stage (4-10 days after onset). Its mean and coefficient of variation (CV) values were calculated and divided into 4 groups according to the quartiles of these BP parameters. Patients were prospectively followed up for recurrent stroke or all-cause death. The cumulative event rate was calculated with the Kaplan-Meier method. We estimated the hazard ratios and 95% confidence intervals of the events of interest after adjusting for potential confounders and mean BP values using Cox proportional hazards models. The Fine-Gray model was also used to account for the competing risk of death. RESULTS: With a mean (±SD) follow-up duration of 3.9±3.2 years, the rates of recurrent stroke and all-cause death were 3.9 and 9.9 per 100 patient-years, respectively. The cumulative event rates of recurrent stroke and all-cause death increased with increasing CVs of systolic BP and diastolic BP. The systolic BP CV was significantly associated with an increased risk of recurrent stroke after adjusting for multiple confounders and mean BP (hazard ratio [95% CI] for fourth quartile versus first quartile, 1.26 [1.05-1.50]); the risk of recurrent stroke also increased with an increasing systolic BP CV for nonfatal strokes (1.26 [1.05-1.51]) and when death was regarded as a competing risk (1.21 [1.02-1.45]). Similar associations were observed for the diastolic BP CV. CONCLUSIONS: Day-by-day variability of BP during the subacute stage of acute ischemic stroke was associated with an increased long-term risk of recurrent stroke.

Home Blood Pressure Monitoring.

Home blood pressure monitoring provides important diagnostic information beyond in-office blood pressure readings and offers similar results to ambulatory blood pressure monitoring. Home blood pressure monitoring involves patients independently measuring their blood pressure with an electronic device, whereas ambulatory blood pressure monitoring involves patients wearing a portable monitor for 24 to 48 hours. Although ambulatory blood pressure monitoring is the diagnostic standard for measurement, home blood pressure monitoring is more practical and accessible to patients, and its use is recommended by the U.S. Preventive Services Task Force and the American College of Cardiology/American Heart Association. Home blood pressure monitoring generally results in lower blood pressure readings than in-office measurements, can confirm the diagnosis of hypertension after an elevated office blood pressure reading, and can identify patients with white coat hypertension or masked hypertension. Best practices for home blood pressure monitoring include using an appropriately fitting upper-arm cuff on a bare arm, emptying the bladder, avoiding caffeinated beverages for 30 minutes before taking the measurement, resting for five minutes before taking the measurement, keeping the feet on the floor uncrossed and the arm supported with the cuff at heart level, and not talking during the reading. An average of multiple readings, ideally two readings in the morning and again in the evening separated by at least one minute each, is recommended for one week. Home blood pressure readings can be used in hypertension quality measures.

Relationship between saline infusion and blood pressure variability in non-critically patients with hypertension: A retrospective study.

Saline is a commonly used intravenous solvent, however, its excessive infusion may increase drug-induced sodium intake. To investigate the effects of saline infusion on blood pressure variability (BPV) in patients with hypertension, a retrospective study was performed in 1010 patients with hypertension. The patients who received saline infusion before surgery for continuous 3 to 5 days were divided into 2 groups according to the saline infusion volume during the hospitalization, which are >500 mL per day group and <500 mL per day group. The overall incidence of abnormal BPV was 11.58%. As for the incidence of abnormal BPV in the <500 mL per day group with 698 patients was 9.17%, while that in the >500 mL per day group with 312 patients was as high as 16.99%. Additionally, >500 mL of daily saline infusion for continuous 3 to 5 days (P for trend = .004, odds ratio [OR] = 1.911, 95% confidence interval [CI] for OR 1.226-2.977), medical history of diabetes mellitus (P < .001, OR = 4.856, 95% CI for OR 3.118-7.563) and cardiovascular diseases (P < .001, OR = 2.498, 95% CI for OR 1.549-4.029) may be risk factors of abnormal BPV; while anti-hypertensive therapy with diuretics (P < .001, OR = 0.055, 95% CI for OR 0.024-0.125) may be the protective factor. Our study suggests that >500 mL of daily saline infusion for continuous 3 to 5 days may have disadvantages in the blood pressure control for hypertensive patients, especially for the patients with diabetes mellitus and cardiovascular diseases.

Improving Hospitalized Children's Sleep by Reducing Excessive Overnight Blood Pressure Monitoring.

BACKGROUND: Although required for healing, sleep is often disrupted during hospitalization. Blood pressure (BP) monitoring can be especially disruptive for pediatric inpatients and has few clinical indications. Our aim in this pilot study was to reduce unnecessary overnight BP monitoring and improve sleep for pediatric inpatients. METHODS: The intervention in June 2018 involved clinician education sessions and updated electronic health record (EHR) orders that enabled the forgoing of overnight BP checks. The postintervention period from July 2018 to May 2019 examined patient-caregiver surveys as outcome measures. These surveys measured inpatient sleep and overnight disruptions and were adopted from validated surveys: the Patient Sleep Questionnaire, expanded Brief Infant Sleep Questionnaire, and Potential Hospital Sleep Disruptions and Noises Questionnaire. Uptake of new sleep-friendly EHR orders was a process measure. Reported patient care escalations served as a balancing measure. RESULTS: Interrupted time series analysis of EHR orders (npre = 493; npost = 1472) showed an increase in intercept for the proportion of patients forgoing overnight BP postintervention (+50.7%; 95% confidence interval 41.2% to 60.3%; P < .001) and a subsequent decrease in slope each week (-0.16%; 95% confidence interval -0.32% to -0.01%; P = .037). Statistical process control of surveys (npre = 263; npost = 131) showed a significant increase in sleep duration for patients older than 2, and nighttime disruptions by clinicians decreased by 19% (P < .001). Annual estimated cost savings were $15 842.01. No major adverse events in patients forgoing BP were reported. CONCLUSIONS: A pilot study combining EHR changes and clinician education safely decreased overnight BP checks, increased pediatric inpatient sleep duration, and reduced nighttime disruptions by clinicians.

Improving blood pressure screening and control at an academic health system.

The goal of the University of California Davis Health Blood Pressure (BP) Quality Improvement Initiative was to improve the diagnosis, management and control of high BP. Patients aged 18-85 years were included in the initiative. Lean A3 problem solving was used to implement the following evidence-based interventions based on stakeholder interviews, value stream mapping and the Centers for Disease Control and Prevention's Million Hearts Initiative: staff training on accurate BP measurement, visual cues and reminders for BP screening, virtual case-based videoconferences, standardised clinical management algorithm, academic detailing visits, clinical decision support tools, access to pharmacists for medication comanagement, clinician workflow modification, patient education and access to home BP monitors. Following implementation of interventions, accurate screening of BP increased from 14% to 87% and BP control increased from 62% to 75%. Strategies that contributed the most to improvements were using a team-based approach, adjusting clinic workflow and frequent communication of results to staff.

Blood pressure reduction and outcome after endovascular therapy with successful reperfusion: a multicenter study.

BACKGROUND: Elevated systolic blood pressure (SBP) after mechanical thrombectomy (MT) correlates with worse outcome. However, the association between SBP reduction (SBPr) and outcome after successful reperfusion with MT is not well established. OBJECTIVE: To investigate the association between SBPr in the first 24 hours after successful reperfusion and the functional and safety outcomes of MT. METHODS: A multicenter retrospective study, which included 10 comprehensive stroke centers, was carried out. Patients with acute ischemic stroke and anterior circulation large vessel occlusions who achieved successful reperfusion via MT were included. SBPr was calculated using the formula 100×([admission SBP-mean SBP]/admission SBP). Poor outcome was defined as a modified Rankin Scale (mRS) score of 3-6 at 90 days. Safety endpoints included symptomatic intracerebral hemorrhage, mortality, and requirement for hemicraniectomy during admission. A generalized mixed linear model was used to study the association between SBPr and outcomes. RESULTS: A total of 1361 patients were included in the final analysis. SBPr as a continuous variable was inversely associated with poor outcome (OR=0.97; 95% CI 0.95 to 0.98; p<0.001) but not with the safety outcomes. Subanalysis based on reperfusion status showed that SBPr was associated with lower odds of poor outcome only in patients with complete reperfusion (modified Thrombolysis in Cerebral Infarction (mTICI 3)) but not in patients with incomplete reperfusion (mTICI 2b). When SBPr was divided into categories (<1%, 1%-10%, 11%-20%, >20%), the rate of poor outcome was highest in the first group. CONCLUSION: SBPr in the first 24 hours after successful reperfusion was inversely associated with poor outcome. No association between SBPr and safety outcome was found.

Early morning home blood pressure control among treated patients with controlled office blood pressure.

Elevated morning blood pressure (BP) has a significantly increased risk of cardiovascular events, so morning BP is of substantial clinical importance for the management of hypertension. This study aimed to evaluate early morning BP control and its determines among treated patients with controlled office BP. From May to October 2018, 600 treated patients with office BP < 140/90 mm Hg were recruited from hypertension clinics. Morning BP was measured at home for 7 days. Morning home systolic blood pressure (SBP) increased by an average of 11.5 mm Hg and that morning home diastolic blood pressure (DBP) increased by an average of 5.6 mm Hg compared with office BP. Morning home SBP, DBP, and their moving average were more likely to be lower among patients with a office SBP < 120 mm Hg than among patients with a office SBP ranging from 120 to 129 mm Hg and from 130 to 139 mm Hg (P < .001). A total of 45% of patients had early morning BP < 135/85 mm Hg. The following factors were significantly correlated with morning BP control: male sex, age of <65 years, absence of habitual snoring, no drinking, adequate physical activity, no habit of high salt intake, office BP < 120/80 mm Hg, and combination of a calcium channel blocker (CCB) and angiotensin receptor blocker or angiotensin-converting enzyme inhibitor (ARB/ACEI). Less than half of patients with controlled office BP had controlled morning BP and that positive changes may be related to an office BP < 120/80 mm Hg, combination of a CCB and ACEI/ARB and a series of lifestyle adjustments.

Predicting hypotension in perioperative and intensive care medicine.

Blood pressure is the main determinant of organ perfusion. Hypotension is common in patients having surgery and in critically ill patients. The severity and duration of hypotension are associated with hypoperfusion and organ dysfunction. Hypotension is mostly treated reactively after low blood pressure values have already occurred. However, prediction of hypotension before it becomes clinically apparent would allow the clinician to treat hypotension pre-emptively, thereby reducing the severity and duration of hypotension. Hypotension can now be predicted minutes before it actually occurs from the blood pressure waveform using machine-learning algorithms that can be trained to detect subtle changes in cardiovascular dynamics preceding clinically apparent hypotension. However, analyzing the complex cardiovascular system is a challenge because cardiovascular physiology is highly interdependent, works within complicated networks, and is influenced by compensatory mechanisms. Improved hemodynamic data collection and integration will be a key to improve current models and develop new hypotension prediction models.

Comparison of manual and automated auscultatory blood pressure during graded exercise among people with type 2 diabetes.

Manual measurement of blood pressure (BP) during exercise testing is the recommended standard. Automated measurement of BP is an alternative method used during clinical exercise testing, but there is little data comparing manual and automated BP in this setting. The aim of this study was to determine the concordance between manual and automated BP during a standard clinical treadmill exercise test. 416 participants (66 ± 5 years; 54% male) completed a Bruce treadmill exercise test at baseline or follow-up within a clinical trial of participants with type 2 diabetes mellitus. Manual and automated BP were measured simultaneously at each exercise test stage. Manual BP was measured by a technician blinded to automated BP values (Tango+, Suntech). Concordance between manual and automated BP was assessed using mean differences and intraclass correlations (ICC). Concordance between manual and automated BP across all exercise stages was excellent for systolic BP (overall mean difference: 3 ± 11 mm Hg, P = .598; ICC = 0.964 [95% CI 0.942-0.977] and pulse pressure (overall mean difference: 2 ± 14 mm Hg, P = .595; ICC = 0.934 [95% CI 0.899-0.956]). Concordance between manual and automated diastolic BP across all exercise stages was moderate-to-good (overall mean difference: 1 ± 9 mm Hg, P = .905; ICC = 0.784 [95% CI 0.672-0.858]). Automated BP using the Tango + device is concordant with manual BP during early stages of a standard clinical exercise test. Thus, this automated method may be a suitable alternative to manual measurement of BP during clinical exercise testing.

Blood pressure and hypertension prevalence among oldest-old in China for 16 year: based on CLHLS.

BACKGROUND: There were little national data on hypertension based on the oldest-old, and lack of information on chronological changes. This study aimed to describe trends of blood pressure (BP) levels and hypertension prevalence for the past 16 years among the oldest-old in China. METHODS: All the oldest-old who had participated in the Chinese Longitudinal Healthy Longevity Survey (CLHLS) 1998 to 2014 with information about BP levels and hypertension were included in the analysis. RESULTS: There was fluctuation over the past 16 years for both SBP and DBP levels. The mean SBP level decreased from 148.4 ± 24.4 mmHg in 1998 to 130.8 ± 18.7 mmHg in 2005, and then increased to 139.7 ± 22.0 mmHg in 2014. The mean DBP level decreased from 84.3 ± 13.4 mmHg in 1998 to 78.9 ± 11.7 mmHg in 2008, and then increased to 79.7 ± 11.8 mmHg in 2014. The hypertension prevalence increased from 43.1 to 56.5% for the 16 years. The prevalence of isolated systolic hypertension was lowest in 2002-2005 (14.3%), and then increased to 30.7% in 2014. Multivariate logistic regression showed that older age, lower education and economic level, without health insurance were associated with higher hypertension prevalence. CONCLUSIONS: There was a significant increase in hypertension prevalence among the Chinese oldest-old from 1998 to 2014. Greater efforts are needed for hypertension prevention among this specific population.

The trend in blood pressure and hypertension prevalence in the general population of South Kivu between 2012 and 2016: Results from two representative cross-sectional surveys-The Bukavu observational study.

OBJECTIVE: Data on blood pressure trends are scarce or unavailable in Sub-Saharan Africa in general and especially in the Democratic Republic of the Congo. This work addresses this gap by analyzing the dynamics in the prevalence and control of hypertension in a cohort of Congolese adults in South Kivu. METHODS: Two phases of data collection were conducted including a baseline at the beginning in 2012 and a follow up in 2016. The subjects were ≥ 18 years old living in urban (n = 4413) or rural areas (n = 6453). Hypertension was defined as a blood pressure ≥ 140/90 mmHg and/or taking antihypertensive medications. The crude prevalence of hypertension was age-adjusted to the WHO population. RESULTS: Between 2012 and 2016, there was a significant increase in blood pressure (+2.5/+1.4 mmHg; p = 0.001), age standardized prevalence of hypertension [19.0% vs. 18.0%; OR = 1.05 (1.02-1.08); p<0.0001], and obesity (7.9% to 9.8%; p<0.0001) as well as the proportion of subjects > 60 years old (8.8% to 11.3%; p<0.0001) and those with tachycardia (10.5% to 14.4%; p<0.0001). The number of subjects under treatment of hypertension were statistically non-significant [16.1% vs. 14.3%; p = 0.29), but the level of control of hypertension was significantly reduced by 32.4% in 2016 compared in 2012 (43.5% vs. 64.4%; p = 0.0008). CONCLUSION: There was an increase in the prevalence of hypertension as well as cardiovascular-associated risk factors in the population. However, this trend did not increase for treated subjects with no improvements in the level of AHT control. Therefore, improved strategies for the prevention and management of non-communicable diseases are very important in Sub-Saharan Africa.

Differences in blood pressure riser pattern in patients with acute heart failure with reduced mid-range and preserved ejection fraction.

AIMS: Heart failure (HF) is classified into three types according to left ventricular ejection fraction (EF). The effect of blood pressure (BP) on the pathogenesis of each type is assumed to be different. However, the association between the prognosis of each type of HF and abnormal BP variations assessed by ambulatory BP monitoring (ABPM), such as nocturnal hypertension and the riser pattern, remains unclear. METHODS AND RESULTS: We studied 325 consecutive patients with decompensated HF who were acutely admitted to our hospital and underwent ABPM at discharge. During a mean follow-up of 30.0 months, 52 cardiovascular and 112 all-cause deaths occurred. The Cox proportional hazards model showed that the mean values of 24 h, awake, and sleep-time systolic BP (SBP), and abnormal 24 h ABPM patterns, such as nocturnal hypertension and non-dipper pattern, were not associated with either all-cause or cardiovascular mortality in patients with HF with reduced EF (HFrEF), HF with mid-range EF (HFmrEF), or HF with preserved EF (HFpEF), except for sleep-time SBP in HFrEF. However, the riser pattern was a significant and independent predictor of all-cause and cardiovascular deaths in patients with HFpEF (hazard ratio, 2.01; 95% confidence interval, 1.12-3.62; 0.0200; and hazard ratio, 2.48; 95% confidence interval, 1.08-5.90; 0.0332, respectively). Sleep-time pulse rate was similarly decreased in both the riser and non-riser groups. CONCLUSIONS: The riser pattern of SBP was associated with an increased risk of adverse outcomes among patients with HFpEF but not HFrEF or HFmrEF.

Trends in Blood Pressure and Usual Dietary Sodium Intake Among Children and Adolescents, National Health and Nutrition Examination Survey 2003 to 2016.

Over the past decade, blood pressure and sodium intake declined among children and adolescents (ie, youths) in the United States. We updated temporal trends and determined if secular changes in blood pressure might be partly associated with usual sodium intake. We included 12 249 youths aged 8 to 17 years who participated in the National Health and Nutrition Examination Survey from 2003 to 2016 and had blood pressure and dietary data. Logistic regression was used to describe secular trends and the association between usual sodium intake and blood pressure categorized according to 2017 Hypertension Guidelines. The prevalence of youths with combined elevated blood pressure/hypertension (ie, either elevated blood pressure or hypertension) significantly declined from 16.2% in 2003-2004 to 13.3% in 2015-2016 ( P<0.001 for trend), as did hypertension from 6.6% to 4.9% ( P=0.005 for trend). Across the same time period, mean usual sodium intake decreased from 3381 to 3208 mg/day ( P<0.001 for trend). Holding constant survey cycle, sex, age, race and Hispanic origin, and weight status, the adjusted odds ratio per 1000 mg/day of usual sodium intake for elevated blood pressure/hypertension was 1.18 (95% CI, 1.03-1.35) and for hypertension was 1.20 (95% CI, 0.96-1.50). From 2003 to 2016, blood pressure and usual sodium intake declined among youths. Although 1000 mg/day higher usual sodium intake was associated with ≈20% higher odds of elevated blood pressure/hypertension and hypertension, the association with hypertension was not statistically significant.