Accuracy and Performance of Triage Blood Pressure Measurements in A Real-World Clinic Setting.

OBJECTIVES: To investigate the agreement and accuracy of triage blood pressure (BP) in a real-world clinic setting, compared with the reference standard. STUDY DESIGN: Paired triage and standardized BP measurements from patients 4 through 21 years old evaluated in an obesity-related hypertension clinic were obtained via chart-review. Triage BPs were measured by a medical assistant or nurse, often by automated device. Triplicate manual BPs were obtained by the clinic physician. Bland-Altman analyses determined mean differences between paired triage and mean standardized BPs. GEE-based multivariable relative risk (RR) regression determined the RR of triage BP overestimation by ≥ 5 mmHg. Overall agreement, sensitivity, specificity, positive predictive value, and negative predictive value of triage BP measurements identifying hypertensive BP were determined. RESULTS: One hundred thirty participants with 347 clinic encounters were included. Mean age was 13.3 years (SD 3.94), 76% were Black, and 58% were male. Overall mean systolic and diastolic BP difference was 8.7 mmHg (95% limits on agreement: -16.66, 34.07) and 4.1 mmHg (95% limits on agreement: -18.56, 26.68), respectively. Triage systolic BP was more likely overestimated by ≥ 5 mmHg when a large adult (RR = 1.49; 95% CI: 1.00, 2.21) or thigh cuff (RR = 1.94; 95% CI: 1.08, 3.51) was required compared with when a child/adult cuff was required. Overall agreement in identifying hypertensive BP was 57.6%. Sensitivity (52.6%), specificity (63.4%), positive predictive value (60.8%), and negative predictive value (55.3%) were low across all cuffs. CONCLUSIONS: There was poor agreement between usual triage and standardized BP measurements, with potential for significant clinical implications. CLINICAL TRIAL REGISTRATION: ReNEW Clinic Cohort Study (ReNEW), NCT03816462, https://clinicaltrials.gov/ct2/show/NCT03816462.

Validation of noninvasive blood pressure monitoring function of EDAN elite V5 patient monitor with reference invasive measurement according to the ISO 81060-2:2018 standard.

OBJECTIVE: To validate the noninvasive blood pressure monitoring function of the EDAN elite V5 patient monitor with reference invasive blood pressure monitoring equipment for clinical use in adults, adolescents or children according to the International Organization for Standardization (ISO) 81060-2:2018 standard. METHODS: Patients were recruited, and the ipsilateral sequential method was used for blood pressure measurement according to the standard. The validation results were assessed following the protocol and the Bland-Altman scatterplot was used to show the difference between the test device and reference invasive blood pressure results. RESULTS: A total of 71 patients were included in the study, with 35 and 36 patients for each iFAST and iCUFS mode, respectively. The validation results showed an average device-reference difference of -3.27 ±â€…5.60 mmHg for SBP and -0.09 ±â€…6.10 mmHg for DBP for the iFAST mode, and -2.04 ±â€…5.55 mmHg for SBP and -0.79 ±â€…5.86 mmHg for DBP for the iCUFS mode, respectively, which passed the criteria of the ISO 81060-2 : 2018 in adults, adolescents or children population for both SBP and DBP. CONCLUSION: The noninvasive blood pressure monitoring function of the EDAN elite V5 patient monitor passed all the requirements of ISO 81060-2:2018 and can be recommended for clinical use in adults, adolescents, or children.

More Evidence That Hypertension Treatment Decisions Shouldn't Depend Solely on In-Office Blood Pressure Readings.

This Medical News feature discusses a recent study that found in-office blood pressure readings varied from visit to visit, supporting the need for more frequent monitoring at home.

Transfer-function-free technique for the noninvasive determination of the human arterial pressure waveform.

The estimation of central aortic blood pressure is a cardinal measurement, carrying effective physiological, and prognostic data beyond routine peripheral blood pressure. Transfer function-based devices effectively estimate aortic systolic and diastolic blood pressure from peripheral pressure waveforms, but the reconstructed pressure waveform seems to preserve features of the peripheral waveform. We sought to develop a new method for converting the local diameter distension waveform into a pressure waveform, through an exponential function whose parameters depend on the local wave speed. The proposed method was then tested at the common carotid artery. Diameter and blood velocity waveforms were acquired via ultrasound at the right common carotid artery while simultaneously recording pressure at the left common carotid artery via tonometer in 203 people (122 men, 50 ± 18 years). The wave speed was noninvasively estimated via the lnDU-loop method and then used to define the exponential function to convert the diameter into pressure. Noninvasive systolic and mean pressures estimated by the new technique were 3.8 ± 21.8 (p = 0.015) and 2.3 ± 9.6 mmHg (p = 0.011) higher than those obtained using tonometery. However, differences were much reduced and not significant in people >35 years (0.6 ± 18.7 and 0.8 ± 8.3 mmHg, respectively). This proof of concept study demonstrated that local wave speed, estimated from noninvasive local measurement of diameter and flow velocity, can be used to determine an exponential function that describes the relationship between local pressure and diameter. This pressure-diameter function can then be used for the noninvasive estimation of local arterial pressure.

Physician perceived barriers and facilitators for self-measured blood pressure monitoring- a qualitative study.

INTRODUCTION: Improving hypertension management is a national priority that can decrease morbidity and mortality. Evidence-based hypertension management guidelines advocate self-measured BP (SMBP), but widespread implementation of SMBP is lacking. The purpose of this study was to describe the perspective of primary care physicians (PCPs) on SMBP to identify the barriers and facilitators for implementing SMBP. METHODS: We collected data from PCPs from a large health system using semi-structured interviews based on the Theoretical Domains Framework (TDF). Responses were recorded, transcribed, and qualitatively analyzed into three overarching TDF domains based on the Behavior Change Wheel (BCW): 1) Motivation 2) Opportunity and 3) Capabilities. The sample size was based on theme saturation. RESULTS: All 17 participating PCPs believed that SMBP is a useful, but underutilized tool. Although individual practices varied, most physicians felt that the increased data points from SMBP allowed for better hypertension management. Most felt that overcoming existing barriers would be difficult, but identified several facilitators: physician support of SMBP, the possibility of having other trained health professionals to assist with SMBP and patient education; improving patient engagement and empowerment with SMBP, and the interest of the health system in using technology to improve hypertension management. CONCLUSION: PCPs believe that SMBP can improve hypertension management. There are numerous barriers and facilitators for implementing SMBP. Successful implementation in clinical practice will require implementation strategies targeted at increasing patient acceptability and reducing physician workload. This may need a radical change in the current methods of managing hypertension.

Exploring the accuracy and precision of BP measurements.

ABSTRACT: Accurate and precise BP measurements are crucial to clinical decision-making and interventions as healthcare professionals aim to prevent complications from hypertension, yet the literature provides no gold standard for measuring BP. This article discusses the additional research necessary to develop best practices and improve patient outcomes.

Blood pressure measurement during cesarean delivery: Evaluation of a beat-to-beat noninvasive device (NexfinTM).

ABSTRACT: Early detection of arterial hypotension during cesarean delivery under spinal anesthesia is important. This study aims to compare the validity of NexfinTM as beat-to-beat noninvasive blood pressure monitoring with conventional intermittent oscillometric measurement of blood pressure during elective cesarean delivery.This open prospective observational bicentric study was performed between January 2013 and December 2015. We simultaneously recorded arterial blood pressure with both techniques in pregnant women undergoing elective cesarean delivery under spinal anesthesia. The primary outcome was a Bland-Altman analysis of systolic blood pressure measurement comparing NexfinTM and a conventional method. The secondary outcomes were the time to detect the first relevant hypotensive episode and the comparison of both devices using a four-quadrant graph.One hundred and seventy-four parturients completed the study, and 2640 pairs of systolic blood pressure measurements were analyzed. Bias was -10 mmHg with upper and lower limits of agreement of -61 and +41 mmHg. In 73.9% of the cases, the two techniques provided the same information (normotension or hypotension), but the conventional method missed 20.8% of measurements, with NexfinTM detecting 16.2% more hypotensive measurements. The median [25-75 percentiles] duration to detect the first hypotensive measurement was 331 [206-480] seconds for NexfinTM and 440 [300-500] s for intermittent oscillometry (P < .001).The agreement between NexfinTM and an intermittent method for the measurement of systolic blood pressure was not in an acceptable range during cesarean delivery, although NexfinTM may detect hypotension earlier than the standard method.Trial registration: Clinicaltrials.gov identifier: NCT01732133; November 22, 2012.

Screening for Hypertension in Adults: US Preventive Services Task Force Reaffirmation Recommendation Statement.

Importance: Hypertension is a prevalent condition that affects approximately 45% of the adult US population and is the most commonly diagnosed condition at outpatient office visits. Hypertension is a major contributing risk factor for heart failure, myocardial infarction, stroke, and chronic kidney disease. Objective: To reaffirm its 2015 recommendation, the US Preventive Services Task Force (USPSTF) commissioned a systematic review to evaluate the benefits and harms of screening for hypertension in adults, the accuracy of office blood pressure measurement for initial screening, and the accuracy of various confirmatory blood pressure measurement methods. Population: Adults 18 years or older without known hypertension. Evidence Assessment: Using a reaffirmation deliberation process, the USPSTF concludes with high certainty that screening for hypertension in adults has substantial net benefit. Recommendation: The USPSTF recommends screening for hypertension in adults 18 years or older with office blood pressure measurement. The USPSTF recommends obtaining blood pressure measurements outside of the clinical setting for diagnostic confirmation before starting treatment. (A recommendation).

Blood Pressure Control Among Older Adults With Hypertension: Narrative Review and Introduction of a Framework for Improving Care.

Although antihypertensive medications are effective, inexpensive, and recommended by clinical practice guidelines, a large percentage of older adults with hypertension have uncontrolled blood pressure (BP). Improving BP control in this population may require a better understanding of the specific challenges to BP control at older age. In this narrative review, we propose a framework for considering how key steps in BP management occur in the context of aging characterized by heterogeneity in function, multiple co-occurring health conditions, and complex personal and environmental factors. We review existing literature related to 4 necessary steps in hypertension control. These steps include the BP measure which can be affected by the technique, device, and setting in which BP is measured. Ensuring proper technique can be challenging in routine care. The plan includes setting BP treatment goals. Lower BP goals may be appropriate for many older adults. However, plans must take into account the generalizability of existing evidence, as well as patient and family's health goals. Treatment includes the management strategy, the expected benefits, and potential risks of treatment. Treatment intensification is commonly needed and can contribute to polypharmacy in older adults. Lastly, monitor refers to the need for ongoing follow-up to support a patient's ability to sustain BP control over time. Sustained BP control has been shown to be associated with a lower rate of cardiovascular disease and multimorbidity progression. Implementation of current guidelines in populations of older adults may be improved when specific challenges to BP measurement, planning, treating, and monitoring are addressed.

Accuracy of abbreviated protocols for unattended automated office blood pressure measurements, a retrospective study.

BACKGROUND: Blood pressure measurement (BPM) is one of the most often performed procedures in clinical practice, but especially office BPM is prone to errors. Unattended automated office BPM (AOBPM) is somewhat standardised and observer-independent, but time and space consuming. We aimed to assess whether an AOBPM protocol can be abbreviated without losing accuracy. DESIGN: In our retrospective single centre study, we used all AOBPM (AOBPM protocol of the SPRINT study), collected over 14 months. Three sequential BPM (after 5 minutes of rest, spaced 2 minutes) were automatically recorded with the patient alone in a quiet room resulting in three systolic and diastolic values. We compared the mean of all three (RefProt) with the mean of the first two (ShortProtA) and the single first BPM (ShortProtB). RESULTS: We analysed 413 AOBPM sets from 210 patients. Mean age was 52±16 years. Mean values for RefProt were 128.3/81.3 mmHg, for ShortProtA 128.4/81.4 mmHg, for ShortProtB 128.8/81.4 mmHg. Mean difference and limits of agreement for RefProt vs. ShortProtA and ShortProtB were -0.1±4.2/-0.1±2.8 mmHg and -0.5±8.1/-0.1±5.3 mmHg, respectively. With ShortProtA, 83% of systolic and 92% of diastolic measurements were within 2 mmHg from RefProt (67/82% for ShortProtB). ShortProtA or ShortProtB led to no significant hypertensive reclassifications in comparison to RefProt (p-values 0.774/1.000/1.000/0.556). CONCLUSION: Based on our results differences between the RefProt and ShortProtA are minimal and within acceptable limits of agreement. Therefore, the automated procedure may be shorted from 3 to 2 measurements, but a single measurement is insufficient.

Elevated serum uric acid is associated with incident hypertension in the health according to various contemporary blood pressure guidelines.

BACKGROUND AND AIMS: Elevated serum uric acid (SUA) is associated with hypertension according to its traditional definition. We investigated the association between SUA and incident hypertension according to the European Society of Cardiology (ESC) and American Society of Cardiology (ACC) guidelines. METHODS AND RESULTS: In this retrospective cohort study, we enrolled 10,537 healthy individuals ≥30 years old who underwent a routine annual health examination with office blood pressure recorded at our hospital in 2016; of the participants, 7349 repeated the exam in 2017. According to the ESC and ACC guidelines, hypertension was defined as office BP ≥ 140/90 mmHg or ≥130/80 mmHg. Hyperuricemia (HUA) was defined as SUA ≥7 mg/dL in men and ≥6 mg/dL in women. The hypertension incidence was 5.8% among 6378 individuals in the ESC cohort and 19% among 4330 individuals in the ACC cohort. Incident hypertension was significantly more common in the hyperuricemic group than in the normouricemic group (ESC: 8.6% vs. 4.7%, P < 0.001; ACC: 25.5% vs. 16.9%, P < 0.001). In the fully adjusted multivariate logistic regression analyses, each increase in SUA was associated with an increase in incident hypertension risk (ESC: adjusted OR: 1.167, 95% CI: 1.061-1.284, P = 0.001; ACC: adjusted OR: 1.125, 95% CI: 1.044-1.213, P = 0.002). The association can be explained by a significant correlation of baseline SUA with the BP in the following year (r = 0.24, P < 0.001 for baseline SUA and SBP in the following year; r = 0.239, P < 0.001 for baseline SUA and DBP in the following year). CONCLUSION: Elevated SUA was associated with incident hypertension in healthy individuals according to various contemporary BP guidelines (ClinicalTrials.gov: NCT03473951). CLINICAL TRIALS: ClinicalTrials.gov with the identification number of NCT03473951.

Association Between Central-Peripheral Blood Pressure Amplification and Structural and Functional Cardiac Properties in Children, Adolescents, and Adults: Impact of the Amplification Parameter, Recording System and Calibration Scheme.

INTRODUCTION: Systolic blood pressure (SBPA) and pulse pressure amplification (PPA) were quantified using different methodological and calibration approaches to analyze (1) the association and agreement between different SBPA and PPA parameters and (2) the association between these SBPA and PPA parameters and left ventricle (LV) and atrium (LA) structural and functional characteristics. METHODS: In 269 healthy subjects, LV and LA parameters were echocardiography-derived. SBPA and PPA parameters were quantified using: (1) different equations (n = 9), (2) methodological approaches (n = 3): brachial sub-diastolic (Mobil-O-Graph®) and supra-systolic oscillometry (Arteriograph®) and aortic diameter waveform re-calibration (RCD; ultrasonography), and (3) using three different calibration schemes: systo-diastolic (SD), calculated mean (CM) and oscillometric mean (OscM). RESULTS: SBPA and PPA parameters obtained with different equations, techniques, and calibration schemes show a highly variable association level (negative, non-significant, and/or positive) among them. The association between SBPA and PPA with cardiac parameters were highly variable (negative, non-significant, or positive associations). Differences in BPA parameter data between approaches were more sensitive to the calibration method than to the device used. Both, SBPA and PPA obtained with brachial sub-diastolic technique and calibrated to CM or OscM showed higher levels of association with LV and LA structural characteristics. CONCLUSIONS: Our data show that many of the parameters that assume to quantify the same phenomenon of BPA are not related to each other in the different age groups. Both, SBPA and PPA obtained with brachial sub-diastolic technique and calibrated to CM or OscM showed higher levels of association with LV and LA structural characteristics.

The 2020 "WHO Technical Specifications for Automated Non-Invasive Blood Pressure Measuring Devices With Cuff".

High systolic blood pressure (BP) is the single leading modifiable risk factor for death worldwide. Accurate BP measurement is the cornerstone for screening, diagnosis, and management of hypertension. Inaccurate BP measurement is a leading patient safety challenge. A recent World Health Organization report has outlined the technical specifications for automated noninvasive clinical BP measurement with cuff. The report is applicable to ambulatory, home, and office devices used for clinical purposes. The report recommends that for routine clinical purposes, (1) automated devices be used, (2) an upper arm cuff be used, and (3) that only automated devices that have passed accepted international accuracy standards (eg, the International Organization for Standardization 81060-2; 2018 protocol) be used. Accurate measurement also depends on standardized patient preparation and measurement technique and a quiet, comfortable setting. The World Health Organization report provides steps for governments, manufacturers, health care providers, and their organizations that need to be taken to implement the report recommendations and to ensure accurate BP measurement for clinical purposes. Although, health and scientific organizations have had similar recommendations for many years, the World Health Organization as the leading governmental health organization globally provides a potentially synergistic nongovernment government opportunity to enhance the accuracy of clinical BP assessment.

The Impact of Various Blood Pressure Measurements on Cardiovascular Outcomes.

Hypertension is a potent risk factor for cardiovascular morbidity and mortality. High blood pressure (BP) correlates closely with all-cause and cardiovascular mortality. Although the gold standard remains office BP (auscultatory or automated), other methods (central or out-of-office) are gaining popularity as better predictors of CV events. In this review, we investigated the prognostic value of each method of BP measurement and explored their advantages and pitfalls. Unattended automated office BP is a novel technique of BP measurement with promising data. Ambulatory BP monitoring, and to a lesser extent, home BP measurements, seem to predict cardiovascular events and mortality outcomes better, while at the same time, they can help distinguish hypertensive phenotypes. Data on the association of central BP levels with cardiovascular and mortality outcomes, are conflicting. Future extensive cross-sectional and longitudinal studies are needed to evaluate head-to-head the corresponding levels and results of each method of BP measurement, as well as to highlight disparities in their prognostic utility.

Prevalence and Risk Factors of Hypertension Among Young Adults in Albania.

INTRODUCTION: Hypertension is one of the major risk factors for cardiovascular disease and the leading cause of death worldwide. Hypertension was defined as systolic or diastolic blood pressure according to Joint National Committee 7 (JNC7) and 2017 American College of Cardiology/American Hypertension Association (ACC/AHA) rules. AIM: The aims of this study was to determine the difference in hypertension prevalence and its risk factors using ACC/AHA rule, and compared its result with JNC7 rule. METHODS: Data were collected using two-stage stratified cluster sample of households from 2017/18 Albanian Demographic and Health Survey. Data were analyzed using the descriptive and multivariate logistic regression model. RESULTS: Among 15,003 respondents aged 15-49 years, the overall prevalence of hypertension was 63.48% and 16.24%, as per ACC/AHA and JNC7 rules, respectively with an absolute increase of prevalence by 47.3% (CI 46.4-48.2%). According to the ACC/AHA rule, in most of the categories of the respondents, the prevalence of hypertension was 40% higher compared with the JNC7 rule. In multivariate analysis, age, education, richest respondents, number of living children (≥ 3), health insurance and gender had significant (p < 0.05) impact on hypertension for both rules. Besides, the middle and richer wealth index, religion, and physically active work had also significant (p < 0.05) impact on hypertension for JNC7 rules. CONCLUSIONS: Newly established ACC/AHA rule led to a significant increase in the proportion of hypertension among the Albanian populations. Similarly, there was a significant difference in the impact of some socioeconomic factors on hypertension as per both rules. Implementation of the prevention and control programs of hypertension are required to increase the awareness of the bad impact of hypertension.

Human Errors in Automated Office Blood Pressure Measurement: Still Room for Improvement.

In this review of the literature and commentary, we examine the literature on automated blood pressure (BP) measurements in the office and clinic. Our purpose is to revisit issues as to the pros and cons of automated BP measurement published in Hypertension in June 2020 and to identify areas needing additional research. Despite initial reservations about automated BP, it is here to stay. A number of experts suggest that human error will be reduced when we move from the more complex skills required by aneroid sphygmomanometer measurement to the fewer skills and steps required by automated BP measurement. Our review indicates there is still need for reduction in errors in automated BP assessment, for example, retraining programs and monitoring of assessment procedures. We need more research on the following questions: (1) which classes of health care providers are least likely to measure BP accurately, usually by ignoring necessary steps; (2) how accurate is BP assessment by affiliated health care providers for example the dental office, the optometrist; and (3) why do some dedicated and well-informed health care professionals fail to follow simple directions for automated BP measurement? We offer additional solutions for improving automated BP assessment in the office and clinic.

Hypertension in Chronic Kidney Disease (CKD): Diagnosis, Classification, and Therapeutic Targets.

Blood pressure (BP) in the office is often recorded without standardization of the technique of measurement. When office BP measurement is performed with a research-grade methodology, it can inform better therapeutic decisions. The reference-standard method of ambulatory BP monitoring (ABPM) together with the assessment of BP in the office enables the identification of white-coat and masked hypertension, facilitating the stratification of cardiorenal risk. Compared with general population, the prevalence of resistant hypertension is 2- to 3-fold higher among patients with chronic kidney disease (CKD). The use of ABPM is mandatory in order to exclude the white-coat effect, a common cause of pseudoresistance, and confirm the diagnosis of true-resistant hypertension. After the premature termination of Systolic Blood Pressure Intervention Trial due to an impressive cardioprotective benefit of intensive BP-lowering, the 2017 American Heart Association/American College of Cardiology guideline reappraised the definition of hypertension and recommended a tighter BP target of <130/80 mm Hg for the majority of adults with a high cardiovascular risk profile, inclusive of patients with CKD. However, the benefit/risk ratio of intensive BP-lowering in particular subsets of patients with CKD (i.e., those with diabetes or more advanced CKD) continues to be debated. We explore the controversial issue of BP targets in CKD, providing a critical evaluation of the available clinical-trial evidence and guideline recommendations. We argue that the systolic BP target in CKD, if BP is measured correctly, should be <120 mm Hg.