K. Kyriakoulis

Treating Visit-to-Visit Blood Pressure Variability to Improve Prognosis: Is Amlodipine the Drug of Choice?

Blood pressure (BP) levels are linearly associated with cardiovascular risk, and hypertension is the most common modifiable risk factor for cardiovascular disease.1 Moreover, antihypertensive treatment-induced BP lowering has been associated with reduction in all outcomes (stroke, heart failure, coronary events, cardiovascular, and all-cause mortality).2 Apart from the established knowledge regarding the importance of hypertension and its effective treatment, during the last years, there has been an increasing interest in the possibility that BP variability (BPV) might carry an additional contribution to cardiovascular risk, on top of the impact of mean BP levels. BP fluctuates constantly and its variability not only may have diagnostic implications regarding the accurate assessment of hypertension but also seems to exert additional stress on the cardiovascular system over and above average BP levels.3 Different components of BPV have been identified, characterized by BP fluctuations between hours, days, or months/years, respectively, termed as short-, mid-, and long-term components.3 All these types of BPV have been shown to carry an independent prognostic value in terms of cardiovascular events and all-cause and cardiovascular mortality.4–10nnThree interesting articles have been recently published in this journal regarding long-term visit-to-visit BPV (VVV). Tedla et al11 showed that an increased VVV among 1122 untreated individuals was predictive of arterial stiffness progression after 10 years of follow-up. The 2 remaining papers reported data on the prognostic value of systolic VVV coming from 2 major trials: the observational extension of the ADVANCE trial (Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation)12 and the SPRINT (Systolic Blood Pressure Intervention Trial).13nnHowever, it seems that at the present time, despite the accumulating evidence on the clinical relevance of VVV, the latter still remains a research tool failing to provide clinical application in …

Atrial Fibrillation Detection During 24-Hour Ambulatory Blood Pressure MonitoringNovelty and Significance: Comparison With 24-Hour Electrocardiography

This study assessed the diagnostic accuracy of a novel 24-hour ambulatory blood pressure (ABP) monitor (Microlife WatchBP O3 Afib) with implemented algorithm for automated atrial fibrillation (AF) detection during each ABP measurement. One hundred subjects (mean age 70.6±8.2 [SD] years; men 53%; hypertensives 85%; 17 with permanent AF; 4 paroxysmal AF; and 79 non-AF) had simultaneous 24-hour ABP monitoring and 24-hour Holter monitoring. Among a total of 6410 valid ABP readings, 1091 (17%) were taken in ECG AF rhythm. In reading-to-reading ABP analysis, the sensitivity, specificity, and accuracy of ABP monitoring in detecting AF were 93%, 87%, and 88%, respectively. In non-AF subjects, 12.8% of the 24-hour ABP readings indicated false-positive AF, of whom 27% were taken during supraventricular premature beats. There was a strong association between the proportion of false-positive AF readings and that of supraventricular premature beats (r=0.67; P<0.001). Receiver operating characteristic curve revealed that in paroxysmal AF and non-AF subjects, AF-positive readings at 26% during 24-hour ABP monitoring had 100%/85% sensitivity/specificity (area under the curve 0.91; P<0.01) for detecting paroxysmal AF. These findings suggest that in elderly hypertensives, a novel 24-hour ABP monitor with AF detector has high sensitivity and moderate specificity for AF screening during routine ABP monitoring. Thus, in elderly hypertensives, a 24-hour ABP recording with at least 26% of the readings suggesting AF indicates a high probability for AF diagnosis and should be regarded as an indication for performing 24-hour Holter monitoring.

DETECTION OF ATRIAL FIBRILLATION DURING ROUTINE 24-HOUR AMBULATORY BLOOD PRESSURE MONITORING IN THE ELDERLY: COMPARISON WITH 24-HOUR ELECTROCARDIOGRAPHY

Objective: To assess the diagnostic accuracy of a novel oscillometric 24-hour ambulatory blood pressure (ABP) monitor (Microlife WatchBP O3 Afib) with implemented algorithm for automated atrial fibrillation (AF) detection during each ABP measurement in elderly hypertensives. Design and method: Elderly subjects (ageu200a>u200a64 years, or 50–64 years, untreated or treated for hypertension, with stroke history or suspected arrhythmias) were subjected to simultaneous 24-hour ABP monitoring and 24-hour electrocardiography (ECG). Results: One hundred subjects (mean age 70.6u200a±u200a8.2 [SD] years, men 53%, hypertensives 85%, 17 with permanent AF, 4 paroxysmal AF, 79 non-AF) were analyzed. Among a total of 6,410 valid ABP readings, 1,091 (17%) were taken in ECG AF rhythm. In reading-to-reading ABP analysis, the sensitivity, specificity and accuracy of the ABP monitor in detecting AF was 93%, 87% and 88% respectively. In non-AF subjects, 12.8% of the 24-hour ABP readings indicated false positive AF, of whom 27% were taken during supraventricular premature beats. There was a strong association between the proportion of false positive AF readings and that of supraventricular premature beats (ru200a=u200a0.67, pu200a<u200a0.001). In paroxysmal AF and non-AF subjects, the receiver operating characteristics curve (area under the curve 0.83, pu200a<u200a0.01) showed that positive AF readings at 15% during 24-hour ABP monitoring had 90% sensitivity and 77% specificity for detecting AF (episode of any duration in 24-hour ECG). Conclusions: A novel 24-hour ABP monitor with AF detecting algorithm has high sensitivity and moderate specificity for AF screening during routine ABP monitoring in elderly hypertensives. AF detected in 15% or more of the 24-hour ABP readings in elderly hypertensives should mandate 24-hour ECG monitoring for suspected AF.

VALIDATION OF THE IHEALTH AMBULATORY BLOOD PRESSURE MONITOR IN ADULTS ACCORDING TO THE ANSI/AAMI/ISO 2013 STANDARD

Objective: To assess the blood pressure (BP) measurement accuracy of the iHealth oscillometric ambulatory BP monitor (iHealthlabs Europe SAS, Paris, France) in adults according to the American National Standards Institute/Association for the Advancement of Medical Instrumentation/International Organization for Standardization 81060–2:2013u200a(ANSI/AAMI/ISO) standard. Design and method: The test device is a fully automated oscillometric ambulatory BP monitor attached on an upper-arm cuff (without tubes) and synchronizes data via Bluetooth with an app running on iPad. Adults were recruited to fulfil the age, gender, BP and cuff distribution criteria of the ANSI/AAMI/ISO standard using the same arm sequential BP measurement method. Two cuffs of the test device were used for arm circumference 22–34 and 30–42u200acm. Results: A total of 100 subjects were recruited and 85 were included in the analysis. For validation criterion 1, the meanu200a±u200aSD of the differences between the test device and reference systolic BP was −0.7u200a±u200a6.0 mmHg and for diastolic 0.7u200a±u200a4.8 mmHg. For validation criterion 2, the SD of the averaged systolic BP differences between the test device and reference method per subject was 4.72 and for diastolic 3.97 mmHg. Conclusions: The iHealth oscillometric ambulatory BP monitor fulfilled the requirements of the ANSI/AAMI/ISO validation standard in adults and can be recommended for clinical use.

AUTOMATED VERSUS AUSCULTATORY OR INTRA-ARTERIAL BLOOD PRESSURE MEASUREMENT IN ATRIAL FIBRILLATION: A SYSTEMATIC REVIEW AND META-ANALYSIS

Objective: The cuff-based measurement of blood pressure (BP) in atrial fibrillation (AF) is considered as difficult and uncertain and the accuracy of automated BP monitors in AF is regarded questionable. Design and method: A systematic PubMed search was conducted for identifying studies comparing automated (oscillometric or automated auscultatory) BP measurements versus manual auscultatory (mercury or aneroid sphygmomanometers) or intra-arterial BP measurements in patients with sustained AF. Results: Fifteen articles including 13 non-invasive studies (Nu200a=u200a877; 5 home, 2 ambulatory, 4 office BP monitors) and 4 invasive studies (Nu200a=u200a179; 2 office, 2 home monitors) were included in meta-analyses. There was a significant heterogeneity in the validation procedure used for comparing BP measurements in different studies. Meta-analysis of non-invasive studies showed pooled correlation coefficients between auscultatory and automated BP measurements to be stronger for systolic (SBP) than diastolic BP (DBP) (r 0.87 versus 0.76, pu200a<u200a0.05). Automated BP measurements were slightly higher than auscultatory measurements (pooled average SBP difference 0.5 mmHg, 95% confidence intervals [CI] −0.9, 1.9; DBP 1.5 mmHg, 95% CI −0.6, 3.6). Meta-analysis of invasive studies showed automated SBP to be lower than intra-arterial SBP measurements (pooled difference −4.2 mmHg, 95% CI −8.4, −0.02), whereas automated DBP was higher (6.1 mmHg, 95% CI: 3.8, 8.4). Conclusions: There is significant heterogeneity in the non-invasive validation studies of automated BP monitors in AF. The current evidence suggests acceptable agreement of automated with auscultatory BP measurements, which is further supported by limited invasive studies showing similar relationship as in sinus rhythm. There seems to be a consistent trend towards more accurate measurement of systolic BP and overestimation of diastolic BP, which however is less important in AF patients who are usually elderly with systolic hypertension.

ATRIAL FIBRILLATION DETECTION DURING AUTOMATED BLOOD PRESSURE MEASUREMENT: A SYSTEMATIC REVIEW AND META-ANALYSIS

Objective: In 2013 the UK National Institute for Health and Care Excellence (NICE) recommended opportunistic atrial fibrillation (AF) screening during routine office blood pressure (BP) measurement using the oscillometric Microlife Afib BP monitor with specific AF detection algorithm in primary care in the elderly. This study evaluated the current evidence on the diagnostic accuracy of this technology in detecting AF during automated BP measurement. Design and method: A systematic PubMed search was conducted using the keywords “atrial fibrillation”, “blood pressure”, “detection”, “screening”. Results: Initial search retrieved 258 articles of which 13 were relevant. Eleven articles evaluated the diagnostic accuracy of BP monitors during office measurements, and 2 during home BP measurements. Electrocardiography was used as reference method in all studies. A meta-analysis of 11 studies with adequate data (nu200a=u200a10,972; AF prevalence 17u200a±u200a12%; 4 studies required at least 2 of 3 AF positive readings for AF diagnosis) showed pooled sensitivity, specificity and accuracy as follows: 95% (95%u200aC.I. 92–98%), 94% (92–96) and 94% (93–96), respectively. With increasing AF prevalence across studies, meta-regression analysis showed a trend towards higher sensitivity and lower specificity. Conclusions: The available evidence suggests that AF detection during automated BP measurement using the Microlife Afib device has high diagnostic accuracy, which is influenced by the AF prevalence. These data support the 2013 UK NICE recommendation for AF screening using automated BP measurement with specific AF detecting algorithm in the elderly.

RELATIONSHIP OF AORTIC AND CAROTID STIFFNESS WITH AMBULATORY BLOOD PRESSURE IN CHILDREN AND YOUNG ADULTS

Objective: Arterial stiffness is an established surrogate measure of preclinical target-organ damage induced by elevated blood pressure (BP). This study assessed regional (aortic) and local (carotid) arterial stiffness measured by different noninvasive methods in children and young adults and their relationship with BP levels. Design and method: Apparently healthy children, adolescents and young adults (age 8–26 years) referred for elevated BP and healthy volunteers were subjected to: (i) 24-hour ambulatory BP (ABP) monitoring, and to simultaneous (ii) M-mode ultrasonography for the assessment of carotid distensibility coefficient, and (iii) determination of aortic pulse wave velocity using noninvasive brachial cuff-based oscillometric device (Mobil-O-Graph 24u200ah PWA). Results: Data from 37 subjects were analyzed (mean age 16.4u200a±u200a5.3 years, 22 males, body mass index [BMI] 24.9u200a±u200a4.5u200akg/m2, 11 with elevated 24-hour ABP [>u200a=u200a95th percentile for children/adolescents oru200a>u200au200a=u200a130/80 mmHg for adults]). There was a significant inverse association between aortic PWV and carotid distensibility coefficient (ru200a=u200a−0.45, pu200a<u200a0.01). Hypertensive compared to normotensive subjects had higher PWV (5.5u200a±u200a0.5 versus 5u200a±u200a0.5u200am/sec respectively, pu200a<u200a0.05 after adjustment for age and gender), but similar carotid distensibility coefficient (46.9u200a±u200a24.2 versus 44.0u200a±u200a14.0 kPa-1x10-3, pu200a=u200aNS). Aortic PWV compared to carotid distensibility coefficient was more strongly correlated with 24-hour systolic ABP (ru200a=u200a0.77 versus −0.46 respectively, pu200a<u200a0.05 for difference). Conclusions: In young individuals aortic PWV as an index of regional stiffness appears to be more closely associated with ABP levels than local carotid stiffness.

[PP.06.15] DETERMINANTS OF WHITE-COAT AND MASKED HYPERTENSION IN THE GENERAL POPULATION: THE DIDIMA STUDY

Objective: White-coat (WCH) and masked hypertension (MH) are common phenotypes between normotension and hypertension. This cross-sectional study investigated the clinical profile associated with increased likelihood for these phenomena. Design and method: Office (1 visit, 3 measurements) and home (3 days, 12 readings) blood pressure (BP) measurements were obtained in a general population study at Didima, Argolida, Greece. Average office and home BP were used to define WCH and MH. Participants’ characteristics (age, gender, BMI, diabetes and cardiovascular disease history, smoking, antihypertensive treatment) were assessed as potential determinants of WCH and MH. Results: 665 adults (age 54.4u200a±u200a17.7 years, 42% men, 14.1% treated, 28.1% with office hypertension) were analyzed. The overall prevalence of WCH and MH was 8.7% and 7.5%, respectively (8.8% and 6.3% in untreated subjects, respectively). In multivariate logistic regression analysis, younger age (pu200a=u200a0.004), untreated status (pu200a=u200a0.044) and lower office BP (pu200a=u200a0.01 for stage I versus stage II hypertension) were independent predictors of WCH among participants with office hypertension. For MH independent predictors were male gender (pu200a=u200a0.034), ageing (pu200a<u200a0.001), obesity (pu200a<u200a0.001), antihypertension treatment (pu200a=u200a0.03) and high-normal office BP (pu200a=u200a0.01) among participants with office normotension. In sensitivity analysis performed in untreated subjects with office hypertension, only female gender (pu200a=u200a0.048) and younger age (pu200a=u200a0.001) increased the odds for WCH. In untreated subjects with low office BP older age (pu200a<u200a0.001), higher BMI (pu200a=u200a0.001), diabetes (pu200a=u200a0.04) and high-normal office BP (pu200a=u200a0.005) independently predicted MH. Figure. No caption available. Conclusions: In this general population study, age, gender, antihypertensive treatment and office BP level consistently predicted WCH and MH.

[OP.1C.07] PROGNOSTIC VALUE OF HOME VERSUS OFFICE BLOOD PRESSURE VARIABILITY: DIDIMA STUDY 19-YEAR FOLLOW-UP

Objective: Accumulating evidence suggests that blood pressure variability (BPV) predicts cardiovascular risk independently of the average blood pressure (BP). This study explored the prognostic ability of home versus office BPV. Design and method: In 1997 all adult population of Didima, Argolida, Greece was invited to participate in a study involving office (2 visits, 6 readings) and home (3 days, 12 readings) BP measurements. Cardiovascular morbidity and mortality were assessed after 19.0u200a±u200a1.4 years (2016). Standard deviation (SD) and coefficient of variation (CV) of home and office BP were used to quantify BPV. Results: 665 participants (age 54.4u200a±u200a17.7 years, 42% men) were analyzed. During follow-up 216 deaths (124 cardiovascular) and 146 cardiovascular events (fatal and non-fatal) were documented. In Cox regression models, all indices of systolic home BPV were predictive of cardiovascular risk, even after adjustment for all available cardiovascular risk factors (adjusted HR 1.05 for a 1-SD increase in systolic home BPV and 1.06 for 1% increment in percentage CV; all pu200a<u200a0.05). The HR for SD (but not CV) of diastolic home BP significantly predicted cardiovascular outcome, yet it lost statistical significance after adjustment for several cardiovascular risk factors (adjusted HR 1.03 for a 1-SD increase in BPV, pu200a=u200aNS). For office BP, only unadjusted indices of BPV were predictive of cardiovascular risk (adjusted HR 1.01/1.03 for a 1-SD increase in systolic/diastolic BPV and 1.02/1.02 for 1% increment in percentage CV; all pu200a=u200aNS). In Cox model including CVs of both home and office systolic BP as independent variables, CV of home BP remained a significant predictor of cardiovascular outcome independent of office BPV. Figure. No caption available. Conclusions: In this long-term general population outcome study, both home and office BPV independently predicted cardiovascular events, with indices of home systolic BPV exhibiting superior prognostic ability.