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Background: Mean systolic and diastolic blood pressure (SBP and DBP) on ambulatory blood pressure (BP) monitoring (ABPM) are higher among Black compared with White adults. With 48 to 72 BP measurements obtained over 24 h, ABPM can generate parameters other than mean BP that are associated with increased risk for cardiovascular events. There are few data on race differences in ABPM parameters other than mean BP., Methods: To estimate differences between White and Black participants in ABPM parameters, we used pooled data from five US-based studies in which participants completed ABPM (n = 2580). We calculated measures of SBP and DBP level, including mean, load, peak, and measures of SBP and DBP variability, including average real variability (ARV) and peak increase., Results: There were 1513 (58.6%) Black and 1067 (41.4%) White participants with mean ages of 56.1 and 49.0 years, respectively. After multivariable adjustment, asleep SBP and DBP load were 5.7% (95% CI: 3.5-7.9%) and 2.7% (95% CI: 1.1-4.3%) higher, respectively, among Black compared with White participants. Black compared with White participants also had higher awake DBP ARV (0.3 [95%CI: 0.0-0.6] mmHg) and peak increase in DBP (0.4 [95% CI: 0.0-0.8] mmHg). There was no evidence of Black:White differences in awake measures of SBP level, asleep peak SBP or DBP, awake and asleep measures of SBP variability or asleep measures of DBP variability after multivariable adjustment., Conclusion: Asleep SBP load, awake DBP ARV and peak increase in awake DBP were higher in Black compared to White participants, independent of mean BP on ABPM., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: To determine the effect of ambulatory blood pressure monitoring (ABPM) on sleep quality among healthy adults and to explore possible effect modification by demographics., Methods: We examined data from 192 relatively healthy young (median age: 31; 33% men, 18% with clinic BP >130/80 mmHg) participants in an observational study of sleep and arterial stiffness. Demographic/health questionnaires were completed. A wrist-based accelerometer assessed sleep for seven nights, and sleep duration, wakefulness after sleep onset (WASO), fragmentation (physical restlessness), midpoint, and efficiency were estimated. ABPM was conducted for one 36-h period, including one actigraphy night., Results: Within-subject comparisons indicated that WASO and fragmentation were higher, midpoint was later, and efficiency was lower on the ABPM night (Ps < 0.001-0.038). Neither age nor sex moderated these associations. Among older adults, a later midpoint and worse fragmentation were observed with ABPM (Ps = 0.002-0.010). There was also a main effect of sex: men demonstrated shorter sleep duration, greater WASO and fragmentation, and less efficiency than women (Ps = 0.002-0.046). With ABPM, women had worse fragmentation and a later midpoint (Ps = 0.002-0.049); for men, WASO and fragmentation were worse (Ps = 0.003-0.023). Importantly, this study does not address whether the effect of wearing ABPM on sleep in turn affects BP during sleep., Conclusions: ABPM appears to modestly disturb actigraphy-assessed sleep among healthy adults. Researchers and clinicians should consider the downstream effects of performing ABPM and whether these effects are more pronounced in those who typically experience sleep disturbance., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: We determined differences in the prevalence of blood pressure (BP) phenotypes and the association of these phenotypes with left ventricular hypertrophy (LVH) for individuals who fulfilled and did not fulfill various criteria used for defining a complete ambulatory blood pressure monitoring (ABPM) recording., Methods: We analyzed data for 1141 participants from the Jackson Heart Study. Criteria evaluated included having greater than or equal to 80% of planned readings with more than or equal to one reading per hour (Spanish ABPM Registry criteria), more than or equal to 70% of planned readings with a minimum of 20 daytime and seven nighttime readings (2013 European Society of Hypertension criteria), greater than or equal to 14 daytime and greater than or equal to seven nighttime readings (2003 European Society of Hypertension criteria), more than or equal to 10 daytime and more than or equal to 5 nighttime readings (International Database of Ambulatory Blood Pressure in Relation to Cardiovascular Outcome criteria), and greater than or equal to 14 daytime readings (UK National Institute of Health and Clinical Excellence criteria)., Results: Between 45.0% (Spanish ABPM Registry) and 91.8% (UK National Institute of Health and Clinical Excellence) of the participants fulfilled the different criteria for a complete ABPM recording. Across the various criteria evaluated, 55.5-57.8% of participants had nocturnal hypertension and 62.8-66.8% had nondipping systolic BP. Among participants with clinic-measured systolic/diastolic BP of more than or equal to 140/90 mmHg, 22.9-26.5% had white-coat hypertension. The prevalence of daytime, 24-h, sustained, and masked hypertension differed by up to 2% for participants fulfilling each criterion. The association of BP phenotypes with LVH was similar for participants who fulfilled versus those who did not fulfill different criteria (each P>0.05)., Conclusion: Irrespective of the criteria used for defining a complete ABPM recording, the prevalence of BP phenotypes and their association with LVH were similar.

Background: Clinic-based blood pressure (CBP) has been the default approach for the diagnosis of hypertension, but patients may be misclassified because of masked hypertension (false negative) or 'white coat' hypertension (false positive). The incorporation of other diagnostic modalities, such as home blood pressure monitoring (HBPM) and ambulatory blood pressure monitoring (ABPM), holds promise to improve diagnostic accuracy and subsequent treatment decisions., Materials and Methods: We reviewed the literature on the costs and cost-effectiveness of adding HBPM and ABPM to routine blood pressure screening in adults. We excluded letters, editorials, and studies of pregnant and/or pre-eclamptic patients, children, and patients with specific conditions (e.g. diabetes)., Results: We identified 14 original, English language studies that included cost outcomes and compared two or more modalities. ABPM was found to be cost saving for diagnostic confirmation following an elevated CBP in six studies. Three of four studies found that adding HBPM to an elevated CBP was also cost-effective., Conclusion: Existing evidence supports the cost-effectiveness of incorporating HBPM or ABPM after an initial CBP-based diagnosis of hypertension. Future research should focus on their implementation in clinical practice, long-term economic values, and potential roles in identifying masked hypertension.

Backgrounds: Although the European Society of Hypertension International Protocol for the validation of blood pressure (BP) measuring devices has simplified the validation protocol, it is still not feasible for use in routine clinical practice., Objectives: We sought to devise a method for validating individual home blood pressure (HBP) monitors that is simple enough for use in routine clinical practice., Methods: We consecutively enrolled 92 hypertensive patients (mean age: 63.2 ± 14.6 years) from the hypertension clinic at the Columbia University Medical Center. Five sequential same-arm BP readings were recorded by a physician: first (D1), second (D2), and fourth (D3) using an HBP device; the third (M1) and fifth (M2) readings were taken manually using a mercury sphygmomanometer. Analyses focused on the absolute values of the differences in the BP values. In step 1, differences D2-M1, M1-D3, and D3-M2 were calculated and if two of three BP differences were within 5 mmHg (or 10 mmHg), the monitor 'passed'. When a monitor failed step 1, if either the difference between M1 and the average of D2 and D3, or the difference between D3 and the average of M1 and M2 was within 5 mmHg (or 10 mmHg), it was judged to have 'passed'., Results: We used only systolic blood pressure to simplify the protocol. In step 1, the number of monitors in which two of three BP differences were within 5 mmHg was 43 (46.7%) and those within 10 mmHg was 73 (79.4%) of 92 total monitors. Of those that failed the 5 mmHg criterion of step 1 (N = 49), 20 passed step 2. Therefore, a total of 63 monitors (68.5%) fulfilled the 5 mmHg criteria. Of 19 monitors that failed step 1 using the 10 mmHg criterion, 12 fulfilled the 10 mmHg criterion for step 2, resulting in 85 of the 92 (92.4%) monitors passing the test., Conclusion: This simplified validation protocol may be of value for the routine evaluation of HBP monitors in clinical practice.

Background: We evaluated the agreement between office blood pressure (OBP) measured by a mercury sphygmomanometer (Sphyg) and an automatic (Auto) device without any observers, and compared Auto and Sphyg OBP with ambulatory blood pressure (ABP) and home blood pressure (HBP)., Methods: OBP was measured in 75 hypertensive patients at two sites using an automatic monitor without a doctor or a nurse present and by Sphyg during three clinic visits. Between visits, monitoring of ABP and HBP was also performed., Results: The mean Auto OBP was similar to that of Sphyg OBP and the values were closely correlated (intraclass correlation coefficient=0.84 for systolic OBP and 0.91 for diastolic OBP); however, the difference between Auto and Sphyg systolic OBP (1.6 ± 8.2 mmHg) varied by the first office visit, sex, and the site. Auto systolic OBP was lower than both systolic awake ABP (137.1 ± 14.7 mmHg) and HBP (139.2 ± 15.6 mmHg). Auto systolic OBP and Sphyg OBP were similarly correlated with systolic awake ABP (both r=0.59, P<0.001). The mean Auto diastolic OBP was similar to that of Sphyg OBP (81.1 ± 11.3 vs. 80.3 ± 13.3 mmHg, P=0.20, intraclass correlation coefficient=0.91), and diastolic awake ABP and HBP. Auto diastolic OBP and Sphyg OBP were related to diastolic awake ABP (both r>0.68, P<0.001). In multivariable analyses, neither OBP measure was a significantly stronger predictor of out-of-office blood pressure than the other., Conclusion: Auto systolic OBP measured without a doctor or a nurse present was lower than systolic awake ABP and HBP. Auto and rigorously assessed Sphyg OBP had similar means and were similarly related to awake ABP. Auto OBP might be an advantageous alternative to Sphyg measurements in the usual clinic setting.

Background: Ambulatory blood pressure (BP) (ABP) is a better predictor of adverse cardiovascular events than office BP (OBP). Owing to the extensive literature on the 'white coat effect', it is widely believed that ABP tends to be lower than OBP, with statements to this effect in Joint National Committee VII. However, recent evidence suggests that the difference varies systematically with age., Methods: We searched PubMed to identify population studies, published before April 2009, which assessed OBP and either ABP or home BP (HBP). On account of significant heterogeneity in the outcomes, random effect models were used for the meta-analyses., Results: OBP increased with age more steeply than awake ABP. OBP became higher than awake systolic/diastolic ABP at the age of 51.3/42.7 years in men (13 studies, N=3562) and 51.9/42.3 years in women (11 studies, N=2585). In the data in which OBP and HBP were measured (eight studies, N=4916), OBP was higher than HBP at all ages. In the data in which OBP, awake ABP, and HBP were all measured (two studies, N=895), awake ABP was higher than HBP at younger ages, becoming similar at the older age., Conclusion: OBP tends to be higher than awake ABP only after the age of 50 years for systolic and after the age of 45 years for diastolic BP, but is lower than ABP at younger ages; in contrast OBP tends to exceed HBP at all ages.

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.

Objective: Cardiovascular prognosis in diabetic white-coat hypertension (WCH) has not yet been described. We designed this study to investigate the impact of WCH on cardiovascular events in patients with type 2 diabetes, compared with those having type 2 diabetes along with sustained hypertension (SH), and with nondiabetic hypertensive individuals., Methods: We performed ambulatory blood pressure (BP) monitoring in 1207 consecutive hypertensive patients at baseline, and they were followed up for 49+/-22 months. The mean age was 70.7+/-9.8 years; 262 had type 2 diabetes; and 945 did not. They were classified as having SH with diabetes (n=210); diabetic WCH (n=52); SH alone (n=719); or WCH alone (n=226), using awake BP of 135/85 mmHg as the cutoff value. Cox regression models were used to calculate hazard ratios (HR) and 95% confidence intervals of the risk for cardiovascular events, after controlling for age, sex, body mass index, current smoking, serum creatinine, and clinical systolic BP., Results: During the follow-up period, 97 cardiovascular events occurred. The incidence of cardiovascular events in the diabetic SH group was significantly higher than in the diabetic WCH, nondiabetic SH, and nondiabetic WCH (P<0.05; log-rank test) groups. In Cox regression analysis, the diabetic SH group had significantly higher risk of cardiovascular events compared with the diabetic WCH group (HR: 8.2; 95% confidence intervals: 1.09-61.8; P=0.04). Although nonsignificant, the HRs in the SH and WCH groups, relative to diabetic WCH, exceeded 3.0., Conclusions: The cardiovascular prognosis for diabetic WCH was better than that for diabetic SH during 4 years of follow-up.

Background: Ambulatory blood pressure is a better predictor of target organ damage and the risk of adverse cardiovascular events than office measurements. Whether this is due to the greater reliability owing to the larger number of measurements that are usually taken using ambulatory monitoring, or the greater validity of these measurements independent of the number, remains controversial., Methods: We addressed this issue by comparing physician readings and ambulatory measurements as predictors of left ventricular mass index. The number of readings was controlled by using the average of three physician readings and randomly selecting three awake readings from a 24-h ambulatory recording., Results: In a multiple regression analysis that included both the ambulatory and physician blood pressure measurements, only the ambulatory systolic measurements significantly predicted left ventricular mass index (B=0.37, t=3.11, P=0.002); the coefficient for physician's systolic measurements was essentially zero (B=-0.01, t=-0.26, NS)., Conclusions: These findings suggest that the superiority of ambulatory blood pressure as a predictor of target organ damage, compared with physician measurements, cannot be adequately/fully explained by the impact of the larger number of measurements obtained with ambulatory monitoring.

Objective: To determine whether elevated clinic blood pressure compared with daytime ambulatory blood pressure, referred to as the white-coat effect, is associated with anxiety and increased blood pressure expectancy in the doctor's office., Methods: The 24-h ambulatory blood pressure measurements and physicians' blood pressure measurements were obtained in 226 normotensive and hypertensive study participants. Anxiety levels were assessed multiple times during the clinic visit using a Visual Analog Scale. Participants' expectations regarding the clinic visit were assessed using a six-item scale (Expectations of Outcomes Scale). The white-coat effect was computed as the difference between the mean clinic blood pressure and the mean daytime ambulatory blood pressure. Multiple regression analysis was performed to examine the association between anxiety, outcome expectations and the white-coat effect, adjusting for age, sex, and ambulatory blood pressure level., Results: As predicted, outcome expectations and anxiety during the clinic visit were significantly associated with the white-coat effect. Results of the regression analysis indicated that only expectancy had an independent effect on the systolic white-coat effect; however, both anxiety and expectancy had independent effects on the diastolic white-coat effect., Conclusion: Our results provide empirical support to the hypothesis that anxiety and blood pressure expectancy may elevate clinic blood pressure.

Background: Automatic blood pressure monitoring conducted at home is increasingly used in the diagnosis and management of hypertension. We assessed the adequacy of existing British Hypertension Society (BHS) and Association for the Advancement of Medical Instrumentation (AAMI) validation standards for automatic blood pressure monitoring devices., Subject and Methods: A theoretical study and an empirical test are presented to estimate the proportion of persons for whom a blood pressure monitor validated according to existing BHS and AAMI standards would be inaccurate., Results: The results suggest that a major limitation of both protocols is the lack of attention given to the number of individual patients for whom a monitor may be inaccurate. A blood pressure monitor that meets the AAMI and BHS validation criteria may report blood pressures in error by more than 5 mmHg for more than half of the people., Conclusions: A validation standard that does not take account of the person-effects on error will lead to a substantial proportion of persons using self-monitors that are systematically inaccurate for that person., (Copyright 2002 Lippincott Williams & Wilkins)

Background: The urinary albumin level has been found to be positively correlated with blood pressure in hypertensive patients. To our knowledge, this relationship has not been evaluated in normotensive subjects and compared with that in hypertensives using casual and ambulatory blood pressure measurements., Methods: In this cross-sectional study, a cohort of 234 normotensive and hypertensive participants wore an ambulatory blood pressure monitor for 24 h, standardized casual blood pressure measurements being taken. The urinary albumin concentration was determined by the dipstick Micral Test. The bivariate and multivariate relationship between urinary albumin concentration and demographic and blood pressure measures was investigated using correlational and regression analyses., Results: The prevalence of microalbuminuria was significantly greater in the hypertensive than normotensive participants. The urinary albumin concentration was positively associated with both casual and ambulatory measures of blood pressure in both the normotensive and hypertensive subsamples, stronger correlations being found for systolic blood pressure. The relationship between systolic blood pressure and urinary albumin concentration was similar in the normotensive and hypertensive subsamples., Conclusions: These findings confirm earlier reports of the greater prevalence of microalbuminuria in patients with hypertension than in normotensive participants, as well as those reporting a continuous relationship in hypertensive participants. This study extends prior research to a normotensive subsample, in whom a similar relationship of blood pressure to microalbuminuria, using both ambulatory and casual measures of blood pressure, was found. Future research should investigate the causal direction of this relationship.