Changing relationship between home and office blood pressure with increasing age in children: the Arsakeion School study.

BACKGROUND: Home blood pressure (HBP) monitoring is being used in children. However, there is no information on the relationship between HBP and office measurements (Office BP (OBP)) in this population. METHODS: This school-based study investigated the effect of age on the difference between HBP and OBP in 765 healthy subjects aged 6-18 years (mean age 12 +/- 3 (SD years)). HBP (3 days, 12 readings) and OBP (2 visits, 6 readings) were measured using electronic devices validated in children (Omron 705IT). RESULTS: Average OBP was slightly lower than HBP by 0.6+/- 7.0 mm Hg (95% confidence intervals (CI) 0.1, 1.1, P=0.01) systolic and 1+/- 6 mm Hg (95% CI 0.7, 1.6, P<0.0001) diastolic, whereas pulse rate was higher in the office by 7+/- 10 beats/min (95% CI 6.2, 7.6, P<0.0001). Age was significantly correlated with the OBP-HBP difference (r = 0.13/0.24 for systolic/diastolic, P< 0.001). In the younger children (6-12 years), both diastolic and systolic HBP were higher than OBP, whereas pulse rate was higher in the office. In older children and adolescents, the BP difference was eliminated whereas the pulse rate difference was reduced but remained significant. These changes with age were similar in boys and girls. CONCLUSIONS: In the pediatric population OBP appears to be higher than HBP. This difference is reduced with advancing age and eliminated after the age of 12 years. These data should be taken into account in the assessment of HBP in children and adolescents.

Home blood pressure normalcy in children and adolescents: the Arsakeion School study.

OBJECTIVE: There is evidence that home blood pressure (BP) is being used in clinical practice for the assessment of out-of-office blood pressure in children. However, there is no information on the normal range of home BP in this population. This prospective school-based study was designed to investigate the normal range of home BP in children and adolescents. SUBJECTS AND METHODS: A total of 778 healthy subjects (358 boys) with mean age 12.3 +/- 3.3 (SD) years (range 6-18 years), height 157 +/- 18 cm (113-198 cm) and weight 50 +/- 18 kg (16-135 kg) were included. Home BP was monitored for 3 days using validated electronic devices (Omron 705IT). RESULTS: Reliable home BP readings provided by 767 subjects (98%) were analysed. Strong correlations were found between systolic home BP and body height (r = 0.49) and age (r = 0.41), whereas for diastolic BP these correlations were poor (r = 0.11 and 0.08, respectively). The 50th (midpoint of distribution) and the 95th percentile (suggested upper normal limit) for systolic and diastolic home BP in children are provided by body height. There was a marked increase in the estimated 95th percentile for systolic home BP with increasing height in boys (from 119 to 134 mmHg) and less so in girls (from 119 to 128 cm). Regarding diastolic home BP, there was little change with increasing height (from 75 to 80 cm) and no difference between boys and girls. CONCLUSIONS: These data suggest that home BP monitoring in children and adolescents is feasible. Reference values for home BP in the paediatric population are provided.

Validation of the Omron 705 IT oscillometric device for home blood pressure measurement in children and adolescents: the Arsakion School Study.

BACKGROUND: Limited evidence exists on the accuracy of oscillometric devices for blood pressure measurement in children. This study validated the Omron 705 IT monitor (Omron Healthcare Europe BV, Hoofddorp, The Netherlands) in normotensive children and adolescents. METHODS: Simultaneous blood pressure measurements were taken by two observers (connected mercury sphygmomanometers) four times, sequentially with three measurements by using the tested device. Absolute device-observer blood pressure differences were classified into three zones (within 5, 10 and 15 mmHg) and assessed using the European Society of Hypertension International Protocol criteria. The number of readings with a difference within 5 mmHg was calculated for each individual. The American Association for the Advancement of Medical Instrumentation criterion (mean difference+ or -SD <5+ or -8 mmHg) was also applied. RESULTS: A total of 197 study participants (591 readings) were included (99 boys, mean age+ or -SD 10.6+ or -2.4 years (range 6-16 years). The device produced 378 (64%), 532 (90%) and 579 (98%) measurements within 5, 10 and 15 mmHg, respectively, for systolic blood pressure, and 415 (70%), 525 (89%) and 577 (98%) measurements, respectively, for diastolic blood pressure. In all, 136 study participants (69%) had at least two systolic blood pressure differences within 5 mmHg and 16 (8%) had no differences within 5 mmHg (for diastolic blood pressure 147 (75%) and nine (5%) participants, respectively). Mean systolic blood pressure difference was 4.0+ or -4.8 mmHg and diastolic blood pressure -2.1+ or -5.9 mmHg and was <5+ or -8 mmHg in quartiles of participants divided by age, height, body mass index, arm circumference, blood pressure or pulse rate. CONCLUSIONS: The Omron 705 IT appears to be an accurate device for blood pressure measurement in normotensive children and adolescents.

White-coat hypertension and masked hypertension in children.

The use of ambulatory blood pressure monitoring in addition to the conventional office measurements makes possible the detection of individuals with white-coat hypertension and masked hypertension. In children referred for elevated blood pressure, both these phenomena appear to be common (10-15% for each). In a population of healthy children, white-coat hypertension appears to be as common as hypertension, whereas masked hypertension appears to be more common than white-coat hypertension or hypertension. In children with persistent white-coat or masked hypertension, assessment of target organ damage by echocardiography is required. Preliminary evidence suggests that, in contrast to white-coat hypertension, which is not associated with target organ damage, masked hypertension in children is associated with increased left ventricular mass. Children with masked hypertension should be followed up and possibly treated for hypertension if the phenomenon persists or there is evidence of target organ damage.

Relationship of home blood pressure with target-organ damage in children and adolescents.

The objective of this study was to compare home blood pressure (HBP) vs. ambulatory (ABP) and clinic (CBP) measurements in terms of their association with target-organ damage in children and adolescents. A total of 81 children and adolescents (mean age 13 ± 3 years, 53 boys) referred for elevated CBP had measurements of CBP (1 visit), HBP (6 days) and ABP (24-h). Seventy-six participants were also assessed with carotid-femoral pulse wave velocity (PWV) and 54 with echocardiography. Average CBP was 122.1 ± 15.1/71 ± 12.9 mm Hg (systolic/diastolic), HBP 121.3 ± 11.5/69.4 ± 6.6 mm Hg and 24-h ABP 118.9 ± 12/66.6 ± 6.1 mm Hg. Left ventricular mass (LVM) was correlated with systolic blood pressure (BP) (coefficient r = 0.55/0.54/0.45 for 24-h/daytime/nighttime ABP, 0.53 for HBP and 0.41 for CBP; all P< 0.01). No significant correlations were found for diastolic BP. PWV was also significantly correlated with systolic BP (r = 0.52/0.50/0.48 for 24-h/daytime/nighttime ABP, 0.50 for HBP and 0.47 for CBP; all P < 0.01). Only diastolic ABP and HBP were significantly correlated with PWV (r = 0.30 and 0.28, respectively, P<0.05). In multivariate stepwise regression analysis (with age, gender, body mass index [BMI], clinic, home and 24-h ambulatory systolic/diastolic BP and pulse pressure, clinic, home and 24-h heart rate as independent variables), PWV was best predicted by systolic HBP (R(2) = 0.22, beta ± s.e. = 0.06 ± 0.01), whereas LVM was determined (R(2) = 0.67) by 24-h pulse pressure (beta = 1.21 ± 0.41), age (beta = 2.93 ± 1.32), 24-h heart rate (beta = -1.27 ± 0.41) and BMI (beta = 1.78 ± 0.70). These data suggest that, in children and adolescents, ABP as well as HBP measurements appear to be superior to the conventional CBP measurements in predicting the presence of subclinical end-organ damage.

Ambulatory arterial stiffness index: reproducibility of different definitions.

BACKGROUND: Ambulatory arterial stiffness index (AASI) has been proposed as a marker of arterial stiffness, which predicts cardiovascular mortality. This study compared the reproducibility of 24-h, daytime, night time, and symmetrical AASI. METHODS: A total of 126 untreated hypertensives (mean age 48.2 +/- 10.7 (s.d.) years, 70 men) underwent 24-h ambulatory blood pressure (ABP) monitoring twice 2-4 weeks apart. The reproducibility of AASI was assessed using the following criteria: (i) repeatability coefficient (RC = 2 x s.d. of differences); (ii) RC expressed as a percentage of close to maximal variation (pMV = RC/(4 x s.d. of the mean of paired recordings)); (iii) coefficient of variation (CV); (iv) concordance correlation coefficient (CCC); (v) agreement (kappa) between the two AASI measurements to detect subjects at the top quartile of the respective AASI distributions. RESULTS: There was no difference in average AASI values between the two assessments. For 24-h, daytime, night time, and symmetrical AASI, respectively, (i) RC values were 0.24, 0.38, 0.42, and 0.30; (ii) pMV 49.6, 68.8, 73.9, and 56; (iii) CV 40.3, 39.3, 62.9, and 116.3; (iv) CCC 0.60, 0.35, 0.28, and 0.52; (v) agreement 82.5% (kappa 0.54), 72.2% (0.28), 73% (0.22), and 81.7% (0.50). Differences in 24-h mean arterial ambulatory pressure (MAP) and in nocturnal MAP decline between the two assessments were significant determinants of the differences in 24-h and symmetrical AASI values. CONCLUSIONS: Although no differences were found in average AASI values of the two ambulatory recordings, significant differences were observed in their reproducibility, with 24-h AASI being the most reproducible measure in terms of all the examined criteria.American Journal of Hypertension 2010; doi:10.1038/ajh.2009.217.

Arterial stiffness index based on home (HASI) vs. ambulatory (AASI) blood pressure measurements.

Ambulatory arterial stiffness index (AASI) is a novel index derived from the linear relationship between 24-h ambulatory systolic and diastolic blood pressure (BP) measurements. This study investigated whether 'home arterial stiffness index' (HASI) based on self-home BP measurements is similar to AASI. A total of 483 hypertensive subjects underwent 24-h ambulatory and 6-day home BP monitoring. AASI and HASI were defined as one minus the respective regression slope of diastolic on systolic BP. Mean HASI (0.66+/-0.17) was higher than 24-h (0.33+/-0.15) daytime (0.50+/-0.18) and nighttime AASI (0.37+/-0.19, P<0.001 for all comparisons vs. HASI) and was weakly correlated with 24-h (r=0.14, P<0.01) daytime (r=0.14, P<0.01) and nighttime AASI (r=0.09, P=0.05). Compared to 24-h AASI, HASI was less closely associated with age (r=0.46 and 0.10 respectively, P<0.001 for difference), systolic home BP (r=0.30 and 0.09, P<0.001) and pulse pressure (r=0.52 and 0.20, P<0.001), as well as with 24-h ambulatory systolic BP (r=0.21 and 0.05, P<0.05) and pulse pressure (r=0.56 and 0.25, P<0.001). No satisfactory agreement was observed between HASI and 24-h (agreement 63%, kappa 0.02) daytime (agreement 65%, kappa 0.1) or nighttime AASI (agreement 63%, kappa 0.03) in detecting subjects at the top quartile of the respective distributions. HASI appears to be similar but also has important differences from AASI and is less closely associated with markers of arterial stiffness. These data do not support the view that home BP measurements can replace ambulatory monitoring in the assessment of the arterial stiffness index.

Prevalence and predictors of masked hypertension detected by home blood pressure monitoring in children and adolescents: the Arsakeion School study.

BACKGROUND: Studies using ambulatory blood pressure (BP) monitoring have shown that in children and adolescents masked hypertension (MH) is not uncommon. This school-based study investigated the prevalence and the characteristics of MH diagnosed using home BP measurements. METHODS: A total of 765 subjects aged 6-18 years were assessed with office (two visits, six readings) and home BP measurements (3 days, 12 readings). Office hypertension was diagnosed using the US Task Force normalcy tables and home hypertension using the Arsakeion normalcy tables (> or = 95th percentile for both). White-coat hypertension (WCH) was defined as office hypertension but low home BP (<95th percentile) and MH as home hypertension but low office BP (<95th percentile). RESULTS: On the basis of office BP measurements of the first visit 3.3% of participants had MH, 5.9% WCH, and 2.7% hypertension compared to 4.2, 2.1, and 1.8%, respectively, when a two-visit-average BP was used (P < 0.001 vs. first visit). Subjects with MH or WCH did not differ from hypertensives or normotensives regarding age, gender, or height. However, weight, body mass index (BMI), waist and hip circumference, and office and home BP values fell in between those of normotensives and hypertensives. Prehypertension (office BP: 90-95th centile) and increased BMI were independent predictors of MH. CONCLUSIONS: In children and adolescents MH detected by home BP monitoring is not uncommon and is associated with prehypertension and overweight. Repeated office measurements are essential for the precise diagnosis. MH and WCH in children appear to be intermediate phenotypes of hypertension.

Long-term reproducibility of home vs. office blood pressure in children and adolescents: the Arsakeion school study.

This study compared the long-term reproducibility of home blood pressure (BP) in comparison with office BP in children and adolescents. Forty-eight subjects (27 boys, mean age 11.3+/-3.1 (s.d.) years) recruited from the Arsakeion school study because of elevated office and/or home BP were assessed with office (1 visit, mercury sphygmomanometer) and home BP measurements (3 days, electronic devices) in two assessments 17+/-4.9 months apart (range 10-26 months). Home and office BP were compared on the basis of the following criteria: (a) s.d. of mean BP; (b) s.d. of differences; (c) variation coefficient (CV); (d) concordance correlation coefficient (CCC); (e) test-retest correlations; (f) correlation with ambulatory BP. (a) The s.d. of mean home BP was lower than that of office BP in both the initial (home BP 9.1/7.1 mm Hg, systolic/diastolic; office BP 13.1/8.0 mm Hg) and the second assessment (9.2/6.0 and 14.9/11.5 respectively). (b) The s.d. of differences was lower for home BP (8.3/6.5 mm Hg, systolic/diastolic) than for office BP (13.9/10.7 mm Hg). (c) The CV of home BP (5.3/6.6, systolic/diastolic) was lower than that of office BP (8.2/10.9). (d) The CCC of home BP (0.54/0.50, systolic/diastolic) was higher than that of office BP (0.51/0.41). (e) Test-retest correlations were closer for home BP (r=0.58/0.52, systolic/diastolic) than for office BP (0.51/0.44). (f) Awake ambulatory BP was more closely associated with home (r=0.77/0.40, systolic/diastolic) than with office BP (0.65/0.24). These data suggest that in children and adolescents the long-term reproducibility of home BP is superior to that of office measurements.