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Diagnostic algorithm for hypertension. BP, blood pressure; DBP, diastolic blood pressure; SBP, systolic blood pressure.

Diagnostic algorithm for hypertension. BP, blood pressure; DBP, diastolic blood pressure; SBP, systolic blood pressure.

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Accurate blood pressure measurement is critical to properly identify and treat individuals with hypertension. In 2005, the Canadian Hypertension Education Program produced a revised algorithm to be used for the diagnosis of hypertension. Subsequent annual reviews of the literature have identified 2 major deficiencies in the current diagnostic proce...

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... present evidence for the need to de-emphasize the use of routine auscultatory OBPM and encourage use of elec- tronic digital devices, and evidence for preferentially using more accurate and reproducible out-of-office methods for earlier and systematic detection of WCH. A revised algorithm ( Fig. 1) for the diagnosis of hypertension is introduced. HBPM and ABPM protocols will be reviewed, and the role of automated office BP (AOBP) ...

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... To minimize motion artifact, clear instructions were given to participants in the case where the monitor performed a reading while they were in a standing position (stop walking with their arm resting at their side). For the BP measurements to be considered, participants had to have at least 20 measures during work time, which is in accordance with more stringent criteria recently recommended by expert committees [24]. Otherwise, the BP value was considered as missing ( Fig. 1). ...
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Population-based strategies targeting modifiable risk factors are needed to improve the prevention of hypertension. Long working hours have been linked to high blood pressure (BP), but more longitudinal research is required. The objective of this study was to examine the effect of long working hours (≥41 h/week) on ambulatory BP mean over a 2.5-year follow-up. The effect modification of family responsibilities was also investigated. A repeated longitudinal design was used. Data collection was performed at three-time points over a 2.5-year follow-up among over 2000 white-collar workers. Working hours were self-reported assessed by questionnaire. BP was measured using Spacelabs 90207. The outcomes were systolic and diastolic BP mean. Cross-lagged GEE linear regressions were used to examine whether working hours were associated with BP means at the next measurement time. Women working long hours had a higher diastolic BP mean at follow-up compared to women working regular hours (+1.8 mm Hg (95% CI: 0.5–3.1)). In men, those working long hours had both higher systolic and diastolic BP means increases (systolic: +2.5 mm Hg (95% CI: 0.5–4.4)) and diastolic: +2.3 mm Hg (95% CI: 1.0–3.7)). This association was greater among workers having high family responsibilities. This longitudinal study showed that women and men working long hours had higher BP means when compared those working 35–40 h per week. These findings suggest that strategies that promote work weeks not exceeding 40 h might contribute to the primary prevention of hypertension, especially for workers with high family responsibilities.
... Several algorithms for the diagnosis of hypertension using ambulatory and home BP measurements have been proposed. [12][13][14][15][16][17] However, most studies focused on diagnosing white-coat hypertension, not on masked hypertension, and did not apply all available office, home, and ambulatory BP measurement methods. Moreover, existing guidelines do not clearly indicate the patients most suitable for ambulatory and home BP measurement for diagnosing hypertension, 5,6 and both are overused. ...
... using out-of-office BP measurements (home and ambulatory BP measurements) to determine white coat and masked hypertension in the diagnosis of hypertension.5,[12][13][14][15][16]22,23 Some focused on detecting white-coat hypertension, not on masked hypertension. ...
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The authors developed and validated a diagnostic algorithm using the optimal upper and lower cut‐off values of office and home BP at which ambulatory BP measurements need to be applied. Patients presenting with high BP (≥140/90 mm Hg) at the outpatient clinic were referred to measure office, home, and ambulatory BP. Office and home BP were divided into hypertension, intermediate (requiring diagnosis using ambulatory BP), and normotension zones. The upper and lower BP cut‐off levels of intermediate zone were determined corresponding to a level of 95% specificity and 95% sensitivity for detecting daytime ambulatory hypertension by using the receiver operator characteristic curve. A diagnostic algorithm using three methods, OBP‐ABP: office BP measurement and subsequent ambulatory BP measurements if office BP is intermediate zone; OBP‐HBP‐ABP: office BP, subsequent home BP measurement if office BP is within intermediate zone and subsequent ambulatory BP measurement if home BP is within intermediate zone; and HBP‐ABP: home BP measurement and subsequent ambulatory BP measurements if home BP is within intermediate zone, were developed and validated. In the development population (n = 256), the developed algorithm yielded better diagnostic accuracies than 75.8% (95%CI 70.1–80.9) for office BP alone and 76.2% (95%CI 70.5–81.3) for home BP alone as follows: 96.5% (95%CI: 93.4–98.4) for OBP‐ABP, 93.4% (95%CI: 89.6–96.1) for OBP‐HBP‐ABP, and 94.9% (95%CI: 91.5–97.3%) for HBP‐ABP. In the validation population (n = 399), the developed algorithm showed similarly improved diagnostic accuracy. The developed algorithm applying ambulatory BP measurement to the intermediate zone of office and home BP improves the diagnostic accuracy for hypertension.
... Participants were given a diary to define daytime (awake) and nighttime (sleep) periods and activities during the 24-hour period. 28 The awakening time was taken from these diaries to calculate the different rMBP measurements. The calculation and definition of rMBP variables are described and illustrated in Figure S2. ...
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Hypertension, elevated morning blood pressure (BP) surges, and circadian BP variability constitute risk factors for cerebrovascular events. Nevertheless, while evidence indicates that hypertension is associated with cognitive dysfunctions, the link between BP variability and cognitive performance during aging is not clear. The purpose of this study is to determine the interaction between relative morning BP, cerebral blood flow (CBF) levels, and cognitive performance in hypertensive older adults with controlled BP under antihypertensive treatment. Eighty-four participants aged between 60 and 75 years old were separated into normotensive (n=51) and hypertensive (n=33) groups and underwent 24-hour ambulatory BP monitoring. They were also examined for CBF in the gray matter (CBF-GM) by magnetic resonance imaging and 5 cognitive domains: global cognition, working memory, episodic memory, processing speed, and executive functions. There was no difference in cognitive performance and CBF between normotensive and controlled hypertensive participants. Through a sensitivity analysis, we identified that, among relative morning BP variables, the best fit for CBF values in this cohort was the morning-evening difference in BP. The relative morning BP was negatively associated with CBF-GM in these hypertensive older adults only. In turn, CBF-GM levels were negatively associated with working and episodic memory scores in hypertensive older adults. This is the first extended study demonstrating an association between high relative morning BP and lower levels of CBF-GM, including the further impact of CBF-GM levels on the cognitive performance of specific domains in a community-based cohort of older adults with hypertension.
... This can go in either of the two directions, over-diagnosing or under-diagnosing. While the first will increase the burden on the healthcare system without any visible cost-effective results, the latter will result in poorer outcomes for the patients with worse prognoses due to increased morbidity and mortality [3]. Hence, accurate assessment should be obtained, according to hypertension Canada's guideline developed by the Canadian Hypertension Education Program (CHEP) published in 2020, a series of steps should be taken to ensure the accuracy of the diagnosis. ...
... Unfortunately, office-based BP measurement is inherently inaccurate and often performed in unstandardized fashion, leading to results that, in up to 30-40% of cases, are poorly reflective of an individual's underlying BP. [15] In terms of inherent inaccuracy, office BP can be spuriously elevated due to white coat effect (resulting in overmedication) and spuriously low due to masked effect (resulting in undertreatment). [16] For these reasons, use of out-of-office BP instead of in-office measurement is strongly endorsed by many clinical practice guidelines, with 24-hour ambulatory BP monitoring preferred for J o u r n a l P r e -p r o o f initial diagnosis and home BP monitoring preferred for follow-up care. ...
... [16][17][18][19] Therefore, the traditional paradigm of diagnosing and managing hypertension using in-person visits and inoffice measurement represents a failure to care for patients according to substantial, rigorous published evidence that has accrued over the last several decades. [15] Use of out-of-office measurement modalities, particularly home BP monitoring, is important from the digital health perspective because it facilitates use of a remote rather than an inperson care paradigm -a 'virtual' model of care for which there is tremendous and increasing interest. [20] The COVID-19 pandemic is an additional factor driving uptake of remote or virtual care is; it has necessitated implementation of actions to minimize person-to-person contact to limit virus transmission. ...
Article
Although many aspects of our lives have been transformed by digital innovation, widespread adoption of digital health advancements within the health care sector in general, and for hypertension care specifically, has been limited. However, it is likely that, over the next decade, material increases in the uptake of digital health innovations for hypertension care delivery will be seen. In this narrative review, we summarize those innovations felt to have the greatest chance for impact in the next decade. These include provision of virtual care combined with home blood pressure (BP) telemonitoring; use of digital registries and protocolized care; leveraging continuous BP measurement to collect vast amounts of individual and population-based BP data; and adoption of digital therapeutics to provide low-cost, scalable interventions for patients with or at risk for hypertension. Of these, home BP telemonitoring is likely the most ready for implementation, but it needs to be done in a way that enables efficient, guideline-concordant care in a cost-effective manner. In addition, efforts must be focused on implementing digital health solutions in a manner that addresses the major challenges to digital adoption. This entails ensuring that innovations are accessible, usable, secure, validated, evidence-based, cost-effective, and integrated into the electronic systems that are already used by patients or providers. Leveraging use of broader digital innovations like artificial/augmented intelligence, data analytics, and interactive voice response is also critically important. The digital revolution holds substantial promise, but success will depend on the ability of collaborative stakeholders to adopt and implement innovative, usable solutions.
... When measuring BP in office, the auscultatory technique can cause inaccuracy and errors in BPM and, therefore, use of electronic oscillometric and/or automated devices is preferred [15,16]. The evidence-based guidelines are established to assist health professionals in decision making for management of hypertension based on clinical judgement for individual patients [11][12][13]. ...
Article
Objective: Guideline-concordant performance of accurate blood pressure measurement (BPM), whether the modality is home (HBPM), ambulatory (ABPM), automated (AOBP) or office (OBPM), is dependent on proper technique. Knowledge, perception and practice of health professionals for BPM is crucial and has been partly studied, but a thorough review has never been reported. A scoping review of global studies was conducted to synthesize published data on this topic. Methods: An Arksey and O'Malley methodological framework was used. Keywords were identified and extraction was completed to April 2019 using CINAHL and MEDLINE. Studies were classified as positive for knowledge, perception and practice if the majority (>50%) of reported responses were favourable, and negative otherwise. If specific results were not reported, the author's conclusions were used to classified. Results: Seventy-two studies were identified: 25 HBPM, 14 ABPM, two AOBP, 40 OBPM. For knowledge, the percentage of negative studies were higher for HBPM (40%) and OBPM (68%) and lower for ABPM (14%) regarding BPM techniques. For perception, the number of negative studies were lower for HBPM (20%) and ABPM (7%) regarding usefulness of BPM methods in hypertension management. For practice, the number of negative studies were higher for HBPM (48%), ABPM (71%), OBPM (73%) and AOBP (50%) regarding implementation of hypertension guidelines. Conclusion: The results of this scoping review demonstrate adequate perception of BPM but suboptimal knowledge and practice. Education is still needed to improve knowledge and practice. Future efforts should focus on improving what we know and what we do when measuring BP.
... El registro ambulatorio de 24 horas y el registro domiciliario de la PA son muy superiores a las mediciones en el consultorio en cuanto a la capacidad de pronosticar complicaciones cardiovasculares [31,32]. El registro de la PA durante 24 horas es el método de referencia para diagnosticar la HTA, y el registro domiciliario de la PA es ideal para el seguimiento a largo plazo de los hipertensos tratados, especialmente cuando se combina con el manejo de casos por parte de enfermeras o farmacéuticos [33][34][35][36]. Si los recursos lo permiten, se recomienda enfáticamente utilizar ambos métodos de medición [30,35,37,38]. ...
... Si los recursos lo permiten, se recomienda enfáticamente utilizar ambos métodos de medición [30,35,37,38]. Las dos modalidades de medición fuera del consultorio requieren una técnica adecuada, y los profesionales de la salud deben comprender que el registro domiciliario de la PA necesita de la capacitación de los pacientes si pretende ser eficaz a la hora de mejorar las decisiones clínicas [33,36,39]. ...
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La hipertensión arterial es una causa modificable muy prevalente de enfermedades cardiovasculares, accidentes cerebrovasculares y muerte. Medir con exactitud la presión arterial es fundamental, dado que un error de medición de 5 mmHg puede ser motivo para clasificar incorrectamente como hipertensas a 84 millones de personas en todo el mundo. En la presente declaración de posición se resumen los procedimientos para optimizar el desempeño del observador al medir la presión arterial en el consultorio, con atención especial a los entornos de ingresos bajos o medianos, donde esta medición se ve complicada por limitaciones de recursos y tiempo, sobrecarga de trabajo y falta de suministro eléctrico. Es posible reducir al mínimo muchos errores de medición con una preparación adecuada de los pacientes y el uso de técnicas estandarizadas. Para simplificar la medición y prevenir errores del observador, deben usarse tensiómetros semiautomáticos o automáticos de manguito validados, en lugar del método por auscultación. Pueden ayudar también la distribución de tareas, la creación de un área específica de medición y el uso de aparatos semiautomáticos o de carga solar. Es fundamental garantizar la capacitación inicial y periódica de los integrantes del equipo de salud. Debe considerarse la implementación de programas de certificación de bajo costo y fácilmente accesibles con el objetivo de mejorar la medición de la presión arterial.
... Inherent in all hypertension management guidelines are specific recommendations to use standardized procedures, appropriate cuff size, and employ validated devices to ensure that measurement is accurate and reproducible. [6][7][8][9][10] The recommendations specify a comfortable, non-stimulating environment, and standardized patient preparation to reduce variation in blood pressure caused by external and internal factors so as to approximate the true basal blood pressure. Standardized techniques in measuring blood pressure are recommended to reduce variation in systemic blood pressure (eg, an unsupported arm or increasing blood pressure because of hydrostatic pressure changes related to the height of the brachial artery relative to the heart). ...
... hour ABPM, HBPM is less expensive, much more widely available also in LA, and provides information about the day-to-day variability of blood pressure.75 On the other hand, there is evidence supporting the superior prognostic value of ABPM vs HBPM. ...
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Out‐of‐office blood pressure (BP) monitoring appears to be a very useful approach to hypertension management insofar it allows to obtain multiple measurements in the usual environment of each individual, allows the detection of hypertension phenotypes, such as white‐coat and masked hypertension, and appears to have superior prognostic value than the conventional office BP measurements. Out‐of‐office BP can be obtained through either home or ambulatory monitoring, which provide complementary and not identical information. Home BP monitoring yields BP values self‐measured in subjects' usual living environment; it is an essential method for the evaluation of almost all untreated and treated subjects with suspected or diagnosed hypertension, best if combined with telemonitoring facilities, also allowing long‐term monitoring. There is also increasing evidence that home BP monitoring improves long‐term hypertension control rates by improving patients' adherence to prescribed treatment. In Latin American Countries, it is widely available, being relatively inexpensive, and well accepted by patients. Current US, Canadian, Japanese, and European guidelines recommend out‐of‐office BP monitoring to confirm and refine the diagnosis of hypertension.
... 3 The routine use of out-of-office monitoring in the diagnosis of hypertension is now also recommended in Canada, the United States, Japan, and Europe. [4][5][6][7] This change was in response to concerns that using clinic blood pressure may result in ≈25% of individuals being misclassified due to white coat hypertension, leading to potential unnecessary costs and adverse events. 8 Furthermore, the use of ambulatory blood pressure monitoring (ABPM), and to a lesser extent home blood pressure monitoring, reduces this misclassification 8 and is cost-effective compared with clinic monitoring. ...
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In recent years, national and international guidelines have recommended the use of out-of-office blood pressure monitoring for diagnosing hypertension. Despite evidence of cost-effectiveness, critics expressed concerns this would increase cardiovascular morbidity. We assessed the impact of these changes on the incidence of hypertension, out-of-office monitoring and cardiovascular morbidity using routine clinical data from English general practices, linked to inpatient hospital, mortality, and socio-economic status data. We studied 3 937 191 adults with median follow-up of 4.2 years (49% men, mean age=39.7 years) between April 1, 2006 and March 31, 2017. Interrupted time series analysis was used to examine the impact of changes to English hypertension guidelines in 2011 on incidence of hypertension (primary outcome). Secondary outcomes included rate of out-of-office monitoring and cardiovascular events. Across the study period, incidence of hypertension fell from 2.1 to 1.4 per 100 person-years. The change in guidance in 2011 was not associated with an immediate change in incidence (change in rate=0.01 [95% CI, −0.18–0.20]) but did result in a leveling out of the downward trend (change in yearly trend =0.09 [95% CI, 0.04–0.15]). Ambulatory monitoring increased significantly in 2011/2012 (change in rate =0.52 [95% CI, 0.43–0.60]). The rate of cardiovascular events remained unchanged (change in rate =−0.02 [95% CI, −0.05–0.02]). In summary, changes to hypertension guidelines in 2011 were associated with a stabilisation in incidence and no increase in cardiovascular events. Guidelines should continue to recommend out-of-office monitoring for diagnosis of hypertension.