The Effectiveness of Home Blood Pressure on 24-Hour Blood Pressure Control: A Randomized Controlled Trial.

BACKGROUND: Home blood pressure monitoring (HBPM) is cited as an effective approach for improving blood pressure control. The objective of this study was to determine the effectiveness of HBPM combined with a health education session in reducing blood pressure and improving medication adherence among adults with hypertension. METHODS: Two hundred thirteen participants were enrolled in a 3-month study and randomized to receive HBPM or usual care. Participants were also randomized to receive an educational session delivered using a pamphlet or a computer-based program. Topics of the educational session included preventing hypertension, managing weight, staying active, and cutting down on salt and fat. RESULTS: At the 3-month follow-up, there was a reduction in ambulatory blood pressure among the HBPM group. However, the differences found within the HBPM group were no greater than those found among the control group. We did not detect a statistically significant difference in adherence to medication when comparing the HBPM to the usual care group. CONCLUSIONS: HBPM and educational session did not lower blood pressure or improve medication adherence in our sample. A greater effect may have been seen if coupled with an enhanced educational intervention and if blood pressure measures were shared with the provided. The findings of this study provide useful insights for future HBPM studies.

Stress management in the workplace for employees with hypertension: a randomized controlled trial.

While behavioral interventions can improve blood pressure (BP) in individuals with hypertension, getting such services to people who could benefit remains difficult. Workplace programs have potential as dissemination vehicles. The objective is to evaluate the effectiveness of a standardized stress management program delivered in groups at the workplace for reducing BP compared with enhanced usual care. This randomized controlled trial studied 92 urban medical center employees with hypertension randomized into two groups. The intervention was a 10-week group workshop on cognitive-behavioral coping skills. Enhanced usual care included self-help materials for BP reduction and physician referral. Intervention group participants' systolic BP (SBP) decreased 7.5 mm Hg over controls between baseline and follow-up, from 149.1 (95% CI: 146.0-152.1) to 140.0 (95% CI: 134.7-145.2), p < .001. The differential change between intervention and enhanced usual care groups (Group × Time interaction) was 7.5 mm Hg (t = -2.05; p = .04). Diastolic BP reductions were not significantly different. Scores on measures of emotional exhaustion and depressive rumination showed significant improvements and correlated with reductions in SBP. There was no significant change in the usual care group. A standardized worksite group intervention produced clinically meaningful reductions in SBP in participants with hypertension.

Revisiting the lack of association between affect and physiology: Contrasting between-person and within-person analyses.

OBJECTIVE: Despite experimental manipulations that reliably elicit affective and physiological responses, the relationship between the two frequently appears small or nonexistent. We propose that this is, at least in part, due to a mismatch between the nature of the question being asked and the analytic methods applied. For example, to test if levels of affect reliably covary with physiology over time-a within-person question-one cannot apply analytic approaches that test whether people are similarly reactive across domains-a between-person question. The purpose of this paper is to compare within-person and between-person analyses testing the association between affect and physiology. METHOD: Participants (N = 60) recalled an event from their lives that made them angry. Self-reported anger and objective blood pressure levels were recorded at baseline, after the recall, and 5 times during recovery. RESULTS: Between-person correlations between anger and blood pressure were nonsignificant across all phases of the study, suggesting that those least/most reactive for anger were not least/most reactive for blood pressure. These null findings held regardless of whether linear or nonlinear assumptions were modeled. In contrast, within-person multilevel modeling indicated a clear relationship, suggesting that when a person was angrier that person's blood pressure was higher compared with when that person was less angry. CONCLUSION: Results suggest the importance of appropriately matching analytic strategy to the nature of the question regarding the relationships between affect and physiology. Implications for past and future research are discussed. (PsycINFO Database Record

Ambulatory blood pressure variability: a conceptual review.

Ambulatory blood pressure (ABP) has long been recognized by researchers as the gold standard of blood pressure (BP) measurement. Researchers and clinicians typically rely on the mean measure of ABP; however, there is considerable variability in the beat-to-beat BP. Although often ignored, this variability has been found to be an independent predictor of cardiovascular disease and mortality. The aim of this paper is to provide a conceptual review of ABP variability (ABPV) focusing on the following: associations between ABPV and health, whether ABPV is reliable, how to calculate ABPV, predictors of ABPV, and treatments for ABPV. Two future directions are discussed involving better understanding ABPV by momentary assessments and improving knowledge of the underlying physiology that explains ABPV. The results of this review suggest that the unique characteristics of ABPV provide insight into the role of BP variability in hypertension and subsequent cardiovascular illness.

Between-person and within-person approaches to the prediction of ambulatory blood pressure: the role of affective valence and intensity.

Identifying momentary influences on ambulatory blood pressure (ABP) will help explain ABP variability; however, most research only examines aggregate ABP at the between-person level. This study used within-person methods to examine whether affective dimensions-valence and arousal-differentially predicted momentary ABP levels. A community sample (n = 39) wore an ABP cuff that took BP measurements every 20 min for 24 h. At each measurement, participants reported levels of valence and arousal on electronic diaries. Multilevel modeling was used to examine the effects of momentary and person-averaged levels of valence and arousal on ABP. Greater momentary negative valence and arousal predicted higher systolic BP compared to more positive or lower arousal assessments; higher averaged levels of arousal predicted higher DBP. The results suggest the independence of the effects of valence and arousal on BP. These findings have important implications for designing interventions to lower ABP.

Hip Hop HEALS: Pilot Study of a Culturally Targeted Calorie Label Intervention to Improve Food Purchases of Children.

OBJECTIVES: We explored the effect of a culturally targeted calorie label intervention on food purchasing behavior of elementary school students. METHOD: We used a quasi-experimental design with two intervention schools and one control school to assess food purchases of third through fifth graders at standardized school food sales before and after the intervention (immediate and delayed) in schools. The intervention comprised three 1-hour assembly-style hip-hop-themed multimedia classes. RESULTS: A mean total of 225 children participated in two baseline preintervention sales with and without calorie labels; 149 children participated in immediate postintervention food sales, while 133 children participated in the delayed sales. No significant change in purchased calories was observed in response to labels alone before the intervention. However, a mean decline in purchased calories of 20% (p < .01) and unhealthy foods (p < .01) was seen in immediately following the intervention compared to baseline purchases, and this persisted without significant decay after 7 days and 12 days. CONCLUSION: A 3-hour culturally targeted calorie label intervention may improve food-purchasing behavior of children.

Tailored approaches to stroke health education (TASHE): study protocol for a randomized controlled trial.

BACKGROUND: Stroke is a leading cause of adult disability and mortality. Intravenous thrombolysis can minimize disability when patients present to the emergency department for treatment within the 3 - 4½ h of symptom onset. Blacks and Hispanics are more likely to die and suffer disability from stroke than whites, due in part to delayed hospital arrival and ineligibility for intravenous thrombolysis for acute stroke. Low stroke literacy (poor knowledge of stroke symptoms and when to call 911) among Blacks and Hispanics compared to whites may contribute to disparities in acute stroke treatment and outcomes. Improving stroke literacy may be a critical step along the pathway to reducing stroke disparities. The aim of the current study is to test a novel intervention to increase stroke literacy in minority populations in New York City. DESIGN AND METHODS: In a two-arm cluster randomized trial, we will evaluate the effectiveness of two culturally tailored stroke education films - one in English and one in Spanish - on changing behavioral intent to call 911 for suspected stroke, compared to usual care. These films will target knowledge of stroke symptoms, the range of severity of symptoms and the therapeutic benefit of calling 911, as well as address barriers to timely presentation to the hospital. Given the success of previous church-based programs targeting behavior change in minority populations, this trial will be conducted with 250 congregants across 14 churches (125 intervention; 125 control). Our proposed outcomes are (1) recognition of stroke symptoms and (2) behavioral intent to call 911 for suspected stroke, measured using the Stroke Action Test at the 6-month and 1-year follow-up. DISCUSSION: This is the first randomized trial of a church-placed narrative intervention to improve stroke outcomes in urban Black and Hispanic populations. A film intervention has the potential to make a significant public health impact, as film is a highly scalable and disseminable medium. Since there is at least one church in almost every neighborhood in the USA, churches have the ability and reach to play an important role in the dissemination and translation of stroke prevention programs in minority communities. TRIAL REGISTRATION: NCT01909271 ; July 22, 2013.

Hip Hop Stroke: Study Protocol for a Randomized Controlled Trial to Address Stroke Literacy.

OBJECTIVE: Stroke is the fifth leading cause of death and the leading cause of serious long-term adult disability in the US. Acute stroke treatments with intravenous thrombolysis and endovascular therapy are proven to reduce disability, however a critical limitation on their effectiveness is the narrow time window for administration, which is 4.5 hours and 6 hours respectively from the onset of symptoms. Our overarching goal is to reduce pre-hospital delays to acute stroke treatments in economically disadvantaged minority communities where the greatest delays exist, using Hip Hop Stroke. METHODS: Hip Hop Stroke (HHS) is a school-based, child-mediated, culturally-tailored stroke communication multimedia intervention developed using validated models of behavior change and designed to improve stroke literacy (knowledge of stroke symptoms, the urgent need to call 911, and prevention measures) of 4th, 5th and 6th grade students and their parents residing in poor urban communities. Children in the intervention arm will receive the HHS intervention, while those in the attentional control arm will receive standardized nutrition education based on the USDA's MyPyramid program. Children will be trained and motivated to share stroke information with their parents or other adult caregiver. Both children and parents will complete a stroke knowledge assessment at baseline, immediately following the program, and at 3-months post-program. The primary outcome is the effect of the child mediation on parental stroke literacy. CONCLUSION: Stroke literate children, a captive audience in school systems, may represent a viable channel for spreading stroke information into households of poor urban communities where mass media stroke campaigns have shown the lowest penetration. These children may also call 911 when witnessing a stroke in their homes or communities. The HHS program may highlight the potential role of children in the chain of stroke recovery as a strategy for reducing prehospital delays to acute stroke treatment.

High trait rumination is associated with blunted nighttime diastolic blood pressure dipping.

BACKGROUND: Blunted blood pressure (BP) dipping during nighttime sleep has been associated with an increased risk of cardiovascular events. Psychological traits have been associated with prolonged cardiovascular activation and a lack of cardiovascular recovery. This activation may extend into nighttime sleep and reduce BP dipping. PURPOSE: This study aims to evaluate the association between trait rumination and nighttime BP dipping. METHODS: Sixty women scoring either high or low on trait rumination underwent one 24-h ambulatory BP monitoring session. Self-reported wake and sleep times were used to calculate nighttime BP. RESULTS: High trait rumination was associated with less diastolic blood pressure (DBP) dipping relative to low trait rumination. Awake ambulatory BP, asleep systolic blood pressure (SBP) and DBP, and asleep SBP dipping were not associated with trait rumination. CONCLUSIONS: In a sample of young women, high trait rumination was associated with less DBP dipping, suggesting that it may be associated with prolonged cardiovascular activation that extends into nighttime sleep, blunting BP dipping.

Absorption in self-selected activities is associated with lower ambulatory blood pressure but not for high trait ruminators.

BACKGROUND: A range of nonpharmacological interventions (e.g., meditation) have positive effects on blood pressure (BP) but tend to have poor adherence. These interventions may lower BP partly by absorbing and directing attention away from one's negative thoughts. We hypothesized that recurring self-selected activities (SSAs) that are attentionally absorbing may similarly lower BP. We examined the effect of reported engagement in SSAs during the previous month prior to participation on ambulatory BP (ABP) and whether those prone to rumination were less likely to show these effects. METHODS: Participants (n = 38) reported engagement in SSAs and how absorbing they were, responded to trait rumination and perceived stress questionnaires, wore an ABP monitor for 24 hours, and at each ABP measurement answered electronic diary questions assessing activity levels, affect, social interactions, and caffeine and tobacco use. RESULTS: Regression analyses tested whether the reported absorption of SSAs, trait rumination, and their interaction predicted daytime and nighttime systolic and diastolic ABP. Greater absorption predicted lower daytime and nighttime ABP (bs = -18.83 to -8.79; Ps < .05), but this relationship was moderated by trait rumination (bs = 3.72 to 9.97; Ps < .05). Follow-up analyses revealed that absorption was unrelated to ABP for those with high trait rumination but that more absorption predicted lower ABP for those less prone to rumination. CONCLUSIONS: Our results suggest that regular engagement in absorbing SSAs is related to lower ABP. These findings have implications for the development of nonpharmacological interventions and suggest SSAs may serve as an adjuvant intervention strategy to lower BP.

Are there consequences of labeling patients with prehypertension? An experimental study of effects on blood pressure and quality of life.

OBJECTIVE: The prehypertension classification was introduced to facilitate prevention efforts among patients at increased risk for hypertension. Although patients who have been told that they have hypertension report worse outcomes than unaware hypertensives, little is known about whether or not prehypertension labeling has negative effects. We evaluated the effects of labeling individuals with prehypertension on blood pressure and health-related quality of life three months later. METHODS: One hundred adults (aged 19 to 82 [mean=40.0] years; 54% women; 64% racial/ethnic minorities) with screening blood pressure in the prehypertensive range (120-139/80-89 mmHg) and no history of diagnosis or treatment of elevated blood pressure were randomly assigned to either a "Labeled" group in which they were informed of their prehypertension, or an "Unlabeled" group in which they were not informed. Subjects underwent office blood pressure measurement, 24-hour ambulatory blood pressure monitoring and completed self-report questionnaires at baseline and at three months. RESULTS: Multilevel mixed effects regression analyses indicated that changes in the white coat effect, office blood pressure, mean daytime ambulatory blood pressure, and physical and mental health did not differ significantly between the two groups. Adjusting for age, sex, race/ethnicity and body mass index did not affect the results. CONCLUSION: These findings suggest that labeling patients with prehypertension does not have negative effects on blood pressure or quality of life. Additional research is needed to develop approaches to communicating with patients about their blood pressure that will maximize the clinical and public health impact of the prehypertension classification.

An extended validation of the ScottCare 320 ambulatory blood pressure monitor: recommendations for clinical application.

OBJECTIVES: The purpose of this study was to validate the ScottCare 320 ambulatory blood pressure monitor (ABPM) using both group-level and individual-level validation procedures. The group-level validation followed a modified protocol of the European Hypertension Society's validation protocol. The individual-level validation was conducted to ensure that the monitor is valid from both a research and clinical perspective. METHODS: Participants (n=41) had three simultaneous blood pressure (BP) measurements taken by a trained listener using a mercury column sphygmomanometer and the ScottCare ABPM, which was used to validate the monitor at the group-level and the first half of the individual-level validation (i.e. the difference between the ABPM and auscultatory means for each participant <5 mmHg). The second half of the individual-level validation occurred by examining participants' responses on diary questionnaires taken immediately following the BP measurements (i.e. can extreme or deviant BP values be explained by situational factors). RESULTS: At the group level, the ABPM passed the criteria laid out by the European Hypertension Society. At the individual level, the difference between the auscultatory and ABPM means was less than 5 mmHg for both systolic and diastolic BP for 36 participants on the initial attempt, and the remaining five on the second attempt. Furthermore, the deviant values were largely attributed to explainable causes, mainly movement. CONCLUSION: The ScottCare ABPM is a highly accurate monitor that can be considered valid at both the group and the individual level, and thus appropriate for both clinical and research use.

Rumination and anxiety mediate the effect of loneliness on depressed mood and sleep quality in college students.

OBJECTIVE: We examined the mechanisms that underlie the observed relationships between loneliness and depressed mood and poor sleep quality in college students. This study was the first to investigate whether rumination and trait anxiety are psychological mechanisms that mediate this relationship. METHODS: In Study 1 (n = 1,244), using factor analysis with cross-sectional data, we established that loneliness and rumination are distinct constructs. We then collected survey data in two cross-sectional samples (ns = 300 and 218) and one prospective (n = 334) sample to test whether rumination and anxiety were mediators of the relationship between loneliness and depressed mood and poor sleep quality. Structural equation modeling was used to test the proposed relationships. Participants completed self-report measures of loneliness, rumination, trait anxiety, depressed mood, and sleep quality. In addition, measures of hostility, neuroticism, negative affect, and tobacco use were also assessed and tested as mediators, while social support was assessed and tested as a moderator. RESULTS: Consistent across the three studies, we found that rumination and trait anxiety fully mediated the associations between loneliness and depressed mood as well as poor sleep quality; these relationships held after testing all other factors. CONCLUSION: This study helps explain how loneliness dynamics relate to poor health and suggests specific points of departure for the development of interventions.

The use of an audience response system in an elementary school-based health education program.

BACKGROUND: The audience response system (ARS) allows students to respond and interact anonymously with teachers via small handheld wireless keypads. Despite increasing popularity in classroom settings, the application of these devices to health education programming has not been studied. We assessed feasibility, engagement, and learning among children using an ARS compared with traditional pencil-paper formats, (ARS) for a stroke health education program. METHOD: We compared outcome data generated via an ARS-based intervention to pencil-paper controls, including test scores and missing data rates among 265 schoolchildren 9 to 11 years old participating in stroke education. Among 119 children, we evaluated the feasibility of ARS use and explored student motivation with a 10-item questionnaire. We assessed facilitator experience with both methods. RESULTS: ARS use is feasible. Students reported having more fun (p < .001), increased attention (p < .001), participation (p < .001), and perceived learning outcomes (p < .001) compared with pencil-paper controls. Test scores showed highly positive improvement for both ARS and paper without additional benefits of ARS on learning. There was no difference in missing data rates (p < .001). Educators preferred the ARS. CONCLUSION: The use of an ARS among children is feasible and improves student and facilitator engagement without additional benefits on stroke learning.

Long-term learning of stroke knowledge among children in a high-risk community.

OBJECTIVES: To evaluate the effect of Hip Hop Stroke, a school-based multimedia musical stroke literacy intervention that targets children aged 8-12 in high-risk minority communities, on the long-term learning of stroke knowledge. METHODS: We enrolled a cohort of 104 fifth and sixth grade children from 2 schools in Central Harlem into a single course of Hip Hop Stroke (3 1-hour classroom sessions, delivered over 3 consecutive days). Tests evaluating knowledge of stroke symptoms and behavioral intent to call 911 using hypothetical stroke scenarios were conducted at baseline, immediately after the intervention, and 15 months after the initial and only intervention. A composite score was created from 5 traditional stroke symptoms plus a distracter (chest pain). Data were analyzed using SAS version 9.2. RESULTS: A total of 104 students completed both pretests (PTs) and immediate posttests (IPs), and 85 students completed all 3 tests, including a 15-month delayed posttest (DP) (81.7% retention rate). At pretest, 55.8% correctly identified calling 911. The baseline composite score was 3.24 (SD 1.45). At IP, stroke knowledge increased significantly across all items: calling 911 (85.6%, p < 0.001) and composite score (5.30, p < 0.0001). At 15 months, stroke knowledge increased significantly from PT for all measures except sudden headache with a composite score of 4.73 (p < 0.0001, PT vs DP). CONCLUSION: Three hours of Hip Hop Stroke significantly improved knowledge of stroke symptoms and behavioral intent to call 911 of fifth and sixth grade children living in a high stroke risk neighborhood. This learning persisted for up to 15 months postintervention.

Rumination as a mediator of chronic stress effects on hypertension: a causal model.

Chronic stress has been linked to hypertension, but the underlying mechanisms remain poorly specified. We suggest that chronic stress poses a risk for hypertension through repeated occurrence of acute stressors (often stemming from the chronic stress context) that cause activation of stress-mediating physiological systems. Previous models have often focused on the magnitude of the acute physiological response as a risk factor; we attempt to extend this to address the issue of duration of exposure. Key to our model is the notion that these acute stressors can emerge not only in response to stressors present in the environment, but also to mental representations of those (or other) stressors. Consequently, although the experience of any given stressor may be brief, a stressor often results in a constellation of negative cognitions and emotions that form a mental representation of the stressor. Ruminating about this mental representation of the stressful event can cause autonomic activation similar to that observed in response to the original incident, and may occur and persist long after the event itself has ended. Thus, rumination helps explain how chronic stress causes repeated (acute) activation of one's stress-mediating physiological systems, the effects of which accumulate over time, resulting in hypertension risk.

Increasing the validity and efficiency of blood pressure estimates using ambulatory and clinic measurements and modern missing data methods.

BACKGROUND: Ambulatory blood pressure monitoring (ABPM) is considered the gold standard for BP measurement, compared to clinic BP measurements (CBP), which are a less valid predictor of target organ damage and cardiovascular events. However, ABPM is considerably more expensive than CBP, leaving BP researchers with a difficult dilemma: Use the less efficient CBP measure, or bear the cost of the more expensive ABPM. Recent developments in missing data methods, notably the two-method measurement (TMM) design, address this problem. With the TMM design, all research participants receive the less expensive CBP measure, but only a random subset receives the more expensive ABPM. The total number of participants must be increased, with additional participants receiving only CBP measurements. Even so, the TMM still reduces costs. METHODS: We applied the TMM approach, which makes use of a "bias correction" structural equation model, to an empirical data set in which data were available for ABPM and CBP, as well as an echocardiographic measure of left ventricular mass (LVM). RESULTS: Based on an estimated fivefold difference in cost for using ABPM compared to CBP, we found that statistical power can be considerably increased, or that BP measurement costs can be considerably reduced, when using this planned missing data design. CONCLUSIONS: These benefits were observed with no loss of predictive validity (i.e., the observed association between BP and LVM). This suggests that the TMM design is a promising technique that in some studies may be able to decrease costs and/or increase one's power to detect effects.

Child-Mediated Stroke Communication: findings from Hip Hop Stroke.

BACKGROUND AND PURPOSE: Low thrombolysis rates for acute ischemic stroke are linked to delays in seeking immediate treatment due to low public stroke awareness. We aimed to assess whether "Child-Mediated Stroke Communication" could improve stroke literacy of parents of children enrolled in a school-based stroke literacy program called Hip Hop Stroke. METHODS: Parents of children aged 9 to 12 years from 2 public schools in Harlem, New York City, were recruited to participate in stroke literacy questionnaires before and after their child's participation in Hip Hop Stroke, a novel Child-Mediated Stroke Communication intervention delivered in school auditoriums. Parental recall of stroke information communicated through their child was assessed 1-week after the intervention. RESULTS: Fifth and sixth grade students (n=182) were enrolled into Hip Hop Stroke. One hundred two parents were approached in person to participate; 75 opted to participate and 71 completed both the pretest and post-test (74% response rate and 95% retention rate). Parental stroke literacy improved after the program; before the program, 3 parents of 75 (3.9%) were able to identify the 5 cardinal stroke symptoms, distracting symptom (chest pains), and had an urgent action plan (calling 911) compared with 21 of 71 parents (29.6%) postintervention (P<0.001). The FAST mnemonic was known by 2 (2.7%) of participants before the program versus 29 (41%) after program completion (P<0.001). CONCLUSIONS: Knowledge of stroke signs and symptoms remains low among residents of this high-risk population. The use of Child-Mediated Stroke Communication suggests that school children aged 9 to 12 years may be effective conduits of critical stroke knowledge to their parents.

Can blood pressure measurements taken in the physician's office avoid the 'white coat' bias?

OBJECTIVE: Obtaining an accurate blood pressure (BP) reading is vital for diagnosing hypertension. However, BP measures taken in the physician's clinic (CBP) are subject to the 'white coat' bias. Measurements taken outside the office using ambulatory (ABP) and home (HBP) monitoring are superior predictors of cardiovascular diseases compared with CBP, but ABP remains underutilized because of the effort and expense involved. Unfortunately, HBP has limitations, including questionable device validity and patient compliance. Thus, it is important to identify feasible alternative techniques to measure BP in the office that will increase the accuracy of the diagnosis. METHODS: Auscultatory BP was measured in 249 patients in a nonclinical setting by trained technicians (NCBP); on the following day, patients were taken to their physician (CBP). They were also given an HBP monitor, and a 36 h ABP monitoring. Because ABP is considered the gold standard for prediction of cardiovascular disease, these readings were used as the criterion in a statistical model in which CBP, HBP, and NCBP were entered as predictors. The level of agreement between measurements was estimated. RESULTS: Multiple regression analysis showed that HBP and NCBP (P < 0.001) explained 94 and 87% of the variance in systolic and diastolic ABP, respectively. The agreement between NCBP and ABP was greater than that between CBP and ABP or between HBP. CONCLUSION: When ABP monitoring and HBP monitoring are not options, the NCBP at the clinic can avoid the white coat bias and therefore improve diagnosis.

Correlations between different measures of clinic, home, and ambulatory blood pressure in hypertensive patients.

OBJECTIVES: It is not well known how clinic, home, and ambulatory measures of blood pressure (BP) correlate with each other. We performed this study to clarify the level of agreement among these different BP measures. MATERIALS AND METHODS: We enrolled 56 hypertensive patients (mean age: 60 ± 14 years; 54% were females). The study consisted of three clinic visits, self-monitoring of home BP between visits, and ambulatory blood pressure (ABP) monitoring at the second visit. Patients were given a home BP monitor programmed to automatically take three consecutive readings at fixed intervals of 1 min. The associations between clinic BP (mercury sphygmomanometer and HEM-5001), home BP (the average of morning and evening, second and third BP readings), and average awake ABP were compared using the intraclass correlation for agreement and Bland-Altman plots. RESULTS: The averages of clinic sphygmomanometer, clinic HEM-5001, awake ABP, and home BP were 129 of 77, 131 of 76, 131 of 79, and 133 of 77 mmHg, respectively. Clinic BP by HEM-5001 was strongly correlated with that of mercury sphygmomanometer. Home systolic blood pressure was moderately correlated with awake ABP, but mercury diastolic blood pressure (DBP) was more closely correlated with awake DBP than home DBP. CONCLUSION: Clinic BP measured with the automated monitor could be used as an alternative for the evaluation of BP in the office. Under rigorously standardized conditions, clinic and home BP could be used as an alternative to awake ABP.