Empar Lurbe

European Society of Hypertension Position Paper on Ambulatory Blood Pressure Monitoring

Ambulatory blood pressure monitoring (ABPM) is being used increasingly in both clinical practice and hypertension research. Although there are many guidelines that emphasize the indications for ABPM, there is no comprehensive guideline dealing with all aspects of the technique. It was agreed at a consensus meeting on ABPM in Milan in 2011 that the 34 attendees should prepare a comprehensive position paper on the scientific evidence for ABPM.This position paper considers the historical background, the advantages and limitations of ABPM, the threshold levels for practice, and the cost-effectiveness of the technique. It examines the need for selecting an appropriate device, the accuracy of devices, the additional information and indices that ABPM devices may provide, and the software requirements.At a practical level, the paper details the requirements for using ABPM in clinical practice, editing considerations, the number of measurements required, and the circumstances, such as obesity and arrhythmias, when particular care needs to be taken when using ABPM.The clinical indications for ABPM, among which white-coat phenomena, masked hypertension, and nocturnal hypertension appear to be prominent, are outlined in detail along with special considerations that apply in certain clinical circumstances, such as childhood, the elderly and pregnancy, and in cardiovascular illness, examples being stroke and chronic renal disease, and the place of home measurement of blood pressure in relation to ABPM is appraised.The role of ABPM in research circumstances, such as pharmacological trials and in the prediction of outcome in epidemiological studies is examined and finally the implementation of ABPM in practice is considered in relation to the issue of reimbursement in different countries, the provision of the technique by primary care practices, hospital clinics and pharmacies, and the growing role of registries of ABPM in many countries.

European Society of Hypertension guidelines for blood pressure monitoring at home: a summary report of the Second International Consensus Conference on Home Blood Pressure Monitoring.

This document summarizes the available evidence and provides recommendations on the use of home blood pressure monitoring in clinical practice and in research. It updates the previous recommendations on the same topic issued in year 2000. The main topics addressed include the methodology of home blood pressure monitoring, its diagnostic and therapeutic thresholds, its clinical applications in hypertension, with specific reference to special populations, and its applications in research. The final section deals with the problems related to the implementation of these recommendations in clinical practice.

Management of high blood pressure in children and adolescents: recommendations of the European Society of Hypertension

Hypertension in children and adolescents has gained ground in cardiovascular medicine, thanks to the progress made in several areas of pathophysiological and clinical research. These guidelines represent a consensus among specialists involved in the detection and control of high blood pressure in children and adolescents. The guidelines synthesize a considerable amount of scientific data and clinical experience and represent best clinical wisdom upon which physicians, nurses and families should base their decisions. They call attention to the burden of hypertension in children and adolescents, and its contribution to the current epidemic of cardiovascular disease, these guidelines should encourage public policy makers, to develop a global effort to improve identification and treatment of high blood pressure among children and adolescents.

Prevalence, Persistence, and Clinical Significance of Masked Hypertension in Youth

Masked hypertension, an elevated daytime ambulatory blood pressure in the presence of a normal office blood pressure, confers an increased cardiovascular risk to adults. We investigated the prevalence, persistence, and clinical significance of masked hypertension in children and adolescents. We enrolled 592 youths (6 to 18 years old). Youths with masked hypertension (n=34) and a random sample of the normotensive participants (n=200) were followed-up. In a nested case-control study, we compared echocardiographic left ventricular mass among cases with persistent masked hypertension and normotensive controls. At baseline, mean age was 10.2 years; 535 youths were normotensive on office and daytime ambulatory blood pressure measurement (90.4%), and 45 had masked hypertension (7.6%). Compared with normotensive controls, participants with masked hypertension had a higher ambulatory pulse rate, were more obese, and were 2.5-times more likely to have a parental history of hypertension. Among 34 patients with masked hypertension (median follow-up 37 months), 18 became normotensive, 13 had persistent masked hypertension, and 3 had sustained hypertension. Patients with persistent masked hypertension (n=17) or who progressed from masked to sustained hypertension (n=3) had a higher left ventricular mass index (34.9 versus 29.6 g/m2.7; P=0.023) and a higher percentage with left ventricular mass index above the 95th percentile (30% versus 0%; P=0.014) than normotensive controls. In children and adolescents, masked hypertension is a precursor of sustained hypertension and left ventricular hypertrophy. This condition warrants follow-up and, once it becomes persistent, is an indication for blood pressure-lowering treatment.

European Society of Hypertension practice guidelines for home blood pressure monitoring.

Self-monitoring of blood pressure by patients at home (home blood pressure monitoring (HBPM)) is being increasingly used in many countries and is well accepted by hypertensive patients. Current hypertension guidelines have endorsed the use of HBPM in clinical practice as a useful adjunct to conventional office measurements. Recently, a detailed consensus document on HBPM was published by the European Society of Hypertension Working Group on Blood Pressure Monitoring. However, in daily practice, briefer documents summarizing the essential recommendations are needed. It is also accepted that the successful implementation of clinical guidelines in routine patient care is dependent on their acceptance by involvement of practising physicians. The present document, which provides concise and updated guidelines on the use of HBPM for practising physicians, was therefore prepared by including the comments and feedback of general practitioners.

European Society of Hypertension practice guidelines for ambulatory blood pressure monitoring

Given the increasing use of ambulatory blood pressure monitoring (ABPM) in both clinical practice and hypertension research, a group of scientists, participating in the European Society of Hypertension Working Group on blood pressure monitoring and cardiovascular variability, in year 2013 published a comprehensive position paper dealing with all aspects of the technique, based on the available scientific evidence for ABPM. The present work represents an updated schematic summary of the most important aspects related to the use of ABPM in daily practice, and is aimed at providing recommendations for proper use of this technique in a clinical setting by both specialists and practicing physicians. The present article details the requirements and the methodological issues to be addressed for using ABPM in clinical practice, The clinical indications for ABPM suggested by the available studies, among which white-coat phenomena, masked hypertension, and nocturnal hypertension, are outlined in detail, and the place of home measurement of blood pressure in relation to ABPM is discussed. The role of ABPM in pharmacological, epidemiological, and clinical research is also briefly mentioned. Finally, the implementation of ABPM in practice is considered in relation to the situation of different countries with regard to the reimbursement and the availability of ABPM in primary care practices, hospital clinics, and pharmacies.

The early life origins of vascular ageing and cardiovascular risk: the EVA syndrome.

Early vascular ageing is common in patients with hypertension and increased burden of cardiovascular risk factors, often influenced by chronic inflammation. One aspect of this vascular ageing is arterial stiffening, as measured by increased pulse wave velocity or augmentation index and central pressure. Several studies have indicated that this process starts early in life and that arterial function and ageing properties could be programmed during foetal life or influenced by adverse growth patterns in early postnatal life. This could explain the repeated findings in observational epidemiology that an inverse association exists between birth weight, adjusted for gestational age, and systolic blood pressure elevation in childhood, adolescence and adulthood, as well as for increased cardiovascular risk. One new marker of increased pulse pressure and arterial ageing is telomere length, as regulated by telomerase enzymatic activity. Future studies will hopefully shed light on the possibilities to halt or even reverse vascular ageing, and thereby also influence telomere biology and its different expressions.

2016 European Society of Hypertension guidelines for the management of high blood pressure in children and adolescents

Increasing prevalence of hypertension (HTN) in children and adolescents has become a significant public health issue driving a considerable amount of research. Aspects discussed in this document include advances in the definition of HTN in 16 year or older, clinical significance of isolated systolic HTN in youth, the importance of out of office and central blood pressure measurement, new risk factors for HTN, methods to assess vascular phenotypes, clustering of cardiovascular risk factors and treatment strategies among others. The recommendations of the present document synthesize a considerable amount of scientific data and clinical experience and represent the best clinical wisdom upon which physicians, nurses and families should base their decisions. In addition, as they call attention to the burden of HTN in children and adolescents, and its contribution to the current epidemic of cardiovascular disease, these guidelines should encourage public policy makers to develop a global effort to improve identification and treatment of high blood pressure among children and adolescents.

The impact of obesity and body fat distribution on ambulatory blood pressure in children and adolescents.

To assess the relationship between obesity, body fat distribution, and blood pressure in children and adolescents, various measures of obesity and the waist-to-hip circumference ratio were related to casual and ambulatory blood pressure as measured using a SpaceLabs 90207 monitor during a regular school day. Seventy obese and 70 nonobese children aged 6 to 16 years were included in the study. Regardless of the time period analyzed (24 h, daytime, or nighttime), ambulatory blood pressure and casual blood pressure were significantly higher among the obese children. The differences in systolic blood pressure observed between the groups were attributable to the presence of obesity as estimated by the ponderal index and by skinfold thickness. Similarly, systolic and diastolic loads, as an assessment of high blood pressure values over 24 h, were significantly higher in the obese children when compared to the loads for the nonobese children. Waist-to-hip circumference ratio was independently associated, (in multiple regression analysis) with systolic blood pressure, whether during 24 h, daytime, or nighttime periods, after controlling for age, sex, current height, ponderal index, and tricipital skinfold thickness. This study demonstrates that obesity is a determinant of ambulatory and casual blood pressure. Since obese children with a predominantly abdominal fat mass show higher blood pressure values, evaluation of body fat distribution in children may help to identify subjects more susceptible to developing hypertension later in life.

Birth Weight Impacts on Wave Reflections in Children and Adolescents

Abstract—The objective of the present study was to assess central aortic pressure and wave reflection in children and adolescents at different birth weights. Two hundred nineteen healthy children (126 girls), from 7 to 18 years of age (mean, 11.3 years) and born at term after a normotensive pregnancy, were included. The subjects were divided according to birth weight: <2.5 kg, from 2.5 to 2.999 kg, from 3.0 to 3.5 kg, and >3.5 kg. Pressure waveforms were recorded from the radial artery of the wrist, and the waveform data were then processed by the SphygmoCor radial/aortic transform software module to produce the estimated aortic pressure waveform. Augmentation index, an estimate of the pulse wave reflection, was significantly higher in children with the lowest birth weights compared with the other birth weight groups. In a multiple regression analysis, short stature, low heart rate, female gender, and lower birth weight had independent significant inverse correlations to the augmentation index when adjusted for diastolic blood pressure (R2=0.21). In summary, the results showed a relatively aged phenotype of large-vessel function in the children with the lowest birth weights. These early alterations may be amplified throughout life and may contribute to the increased cardiovascular risk associated with low birth weight.