Nadia Boubouchairopoulou

Association of Central Versus Brachial Blood Pressure With Target-Organ Damage Systematic Review and Meta-Analysis

Accumulating evidence suggests that central blood pressure (BP) may reflect the hemodynamic stress on target organs more accurately than brachial BP. A systematic review assessing the relationship of central versus brachial BP with preclinical target-organ damage was performed. Meta-analysis of cross-sectional data showed that central compared with brachial systolic BP was more closely associated with (1) left ventricular mass index (12 studies, n=6431; weighted age [SD], 49.9 [13.1] years; 51% hypertensives): pooled correlation coefficients r=0.30; 95% confidence interval (CI), 0.23–0.37 versus r=0.26; 95% CI, 0.19–0.33, respectively; P<0.01 for difference; (2) carotid intima-media thickness (7 studies, n=6136; weighted age, 55.6 [13.2] years; 48% hypertensives): r=0.27; 95% CI, 0.19–0.34 versus r=0.23; 95% CI, 0.16–0.30, respectively; P<0.01 for difference; (3) pulse-wave velocity (14 studies, n=3699; weighted age, 53.9 [13.3] years; 53% hypertensives): r=0.42; 95% CI, 0.37–0.47 versus r=0.39; 95% CI, 0.33–0.45, respectively; P<0.01 for difference. Four studies assessing urine albumin excretion (n=3718; weighted age, 56.4 [5] years; 69% hypertensives) reported similar correlations (P=not significant) with central (r=0.22; 95% CI, 0.14–0.29) and brachial systolic BP (r=0.22; 95% CI, 0.12–0.32). Similar findings were observed for central compared with brachial pulse pressure in terms of relationship with target-organ damage. Metaregression analyses did not reveal any significant effect of age. In conclusion, central compared with brachial BP seems to be more strongly associated with most of the investigated indices of preclinical organ damage.

Association of Central Versus Brachial Blood Pressure With Target-Organ Damage

Accumulating evidence suggests that central blood pressure (BP) may reflect the hemodynamic stress on target organs more accurately than brachial BP. A systematic review assessing the relationship of central versus brachial BP with preclinical target-organ damage was performed. Meta-analysis of cross-sectional data showed that central compared with brachial systolic BP was more closely associated with (1) left ventricular mass index (12 studies, n=6431; weighted age [SD], 49.9 [13.1] years; 51% hypertensives): pooled correlation coefficients r=0.30; 95% confidence interval (CI), 0.23–0.37 versus r=0.26; 95% CI, 0.19–0.33, respectively; P<0.01 for difference; (2) carotid intima-media thickness (7 studies, n=6136; weighted age, 55.6 [13.2] years; 48% hypertensives): r=0.27; 95% CI, 0.19–0.34 versus r=0.23; 95% CI, 0.16–0.30, respectively; P<0.01 for difference; (3) pulse-wave velocity (14 studies, n=3699; weighted age, 53.9 [13.3] years; 53% hypertensives): r=0.42; 95% CI, 0.37–0.47 versus r=0.39; 95% CI, 0.33–0.45, respectively; P<0.01 for difference. Four studies assessing urine albumin excretion (n=3718; weighted age, 56.4 [5] years; 69% hypertensives) reported similar correlations (P=not significant) with central (r=0.22; 95% CI, 0.14–0.29) and brachial systolic BP (r=0.22; 95% CI, 0.12–0.32). Similar findings were observed for central compared with brachial pulse pressure in terms of relationship with target-organ damage. Metaregression analyses did not reveal any significant effect of age. In conclusion, central compared with brachial BP seems to be more strongly associated with most of the investigated indices of preclinical organ damage.

Methodology and technology for peripheral and central blood pressure and blood pressure variability measurement: Current status and future directions - Position statement of the European Society of Hypertension Working Group on blood pressure monitoring and cardiovascular variability

Office blood pressure measurement has been the basis for hypertension evaluation for almost a century. However, the evaluation of blood pressure out of the office using ambulatory or self-home monitoring is now strongly recommended for the accurate diagnosis in many, if not all, cases with suspected hypertension. Moreover, there is evidence that the variability of blood pressure might offer prognostic information that is independent of the average blood pressure level. Recently, advancement in technology has provided noninvasive evaluation of central (aortic) blood pressure, which might have attributes that are additive to the conventional brachial blood pressure measurement. This position statement, developed by international experts, deals with key research and practical issues in regard to peripheral blood pressure measurement (office, home, and ambulatory), blood pressure variability, and central blood pressure measurement. The objective is to present current achievements, identify gaps in knowledge and issues concerning clinical application, and present relevant research questions and directions to investigators and manufacturers for future research and development (primary goal).

Determinants of the direct cost of heart failure hospitalization in a public tertiary hospital

BACKGROUND Heart failure (HF) is the first reason for hospital admission in the elderly and represents a major financial burden, the greatest part of which results from hospitalization costs. We sought to analyze current HF hospitalization-related expenditure and identify predictors of cost in a public tertiary hospital in Europe. METHOD We performed a retrospective chart review of 197 consecutive patients, aged 56±16years, 80% male, with left ventricular ejection fraction (LVEF) of 30±10%, hospitalized for HF in a major university hospital in Athens, Greece. The survey involved the number of hospitalization days, laboratory investigations and medical therapies. Patients who were hospitalized in CCU/ICU or underwent interventional procedures or device implantations were excluded from analysis. Costs were estimated based on the Greek healthcare system perspective in 2013. RESULTS Patients were hospitalized for a median of 7 days with a total direct cost of €3198±3260/patient. The largest part of the expenses (79%) was attributed to hospitalization (ward), while laboratory investigations and medical treatment accounted for 17% and 4%, respectively. In multivariate analysis, pre-admission New York Heart Association NYHA class (p=0.001), serum creatinine (p=0.003) and NT-proBNP (p=0.004) were significant independent predictors of hospitalization cost. CONCLUSION Direct cost of HF hospitalization is high particularly in patients with more severe symptoms, profound neurohormonal activation and renal dysfunction. Strategies to lower hospitalization rates are warranted in the current setting of financial constraints faced by many European countries.

Accuracy of Automated Blood Pressure Measurement in Children: Evidence, Issues, and Perspectives

There is a general consensus in the European1 and American2 guidelines for pediatric hypertension that children from 3 years of age and older who are seen in a medical setting should have their blood pressure (BP) measured. This is because hypertension in children and adolescents has become an emerging public health issue, with increasing prevalence mainly driven by the obesity epidemic in this population.1,2 Because hypertension is almost always asymptomatic until there is severe organ damage or it evolves into a malignant phase, the only method for early detection and intervention aiming to prevent its complications is the measurement of BP. The accurate measurement of BP is a prerequisite in the adults and in children for the reliable diagnosis of hypertension and the avoidance of misdiagnosis and over- or undertreatment.1,2 The main methods for noninvasive measurement of BP are the auscultatory method using conventional mercury or aneroid devices and the automated method using electronic, mostly oscillometric, devices.3 This article aims to discuss the evidence and the issues of automated BP measurement in children (age 3–12 years). Current guidelines for pediatric hypertension in Europe1 and the United States2 recommend the auscultatory BP measurement method for the diagnosis of hypertension in children. If elevated BP in children is detected by an electronic (oscillometric) BP monitor, it should be confirmed by auscultatory BP measurement.1,2 This is mainly because in children, the available reference values for defining the threshold for hypertension diagnosis have been obtained by the auscultatory method and the fact that auscultatory and automated electronic BP measurements are not necessarily interchangeable.1 In children, the auscultatory BP measurement encounters several obstacles, mainly because of anatomic and physiological characteristics of the young individuals. These include small arm dimensions, small …

Relationship between office and home blood pressure with increasing age: The International Database of HOme blood pressure in relation to Cardiovascular Outcome (IDHOCO)

Home blood pressure (HBP) measurements are known to be lower than conventional office blood pressure (OBP) measurements. However, this difference might not be consistent across the entire age range and has not been adequately investigated. We assessed the relationship between OBP and HBP with increasing age using the International Database of HOme blood pressure in relation to Cardiovascular Outcome (IDHOCO). OBP, HBP and their difference were assessed across different decades of age. A total of 5689 untreated subjects aged 18–97 years, who had at least two OBP and HBP measurements, were included. Systolic OBP and HBP increased across older age categories (from 112 to 142 mm Hg and from 109 to 136 mm Hg, respectively), with OBP being higher than HBP by ∼7 mm Hg in subjects aged >30 years and lesser in younger subjects (P=0.001). Both diastolic OBP and HBP increased until the age of ∼50 years (from 71 to 79 mm Hg and from 66 to 76 mm Hg, respectively), with OBP being consistently higher than HBP and a trend toward a decreased OBP–HBP difference with aging (P<0.001). Determinants of a larger OBP–HBP difference were younger age, sustained hypertension, nonsmoking and negative cardiovascular disease history. These data suggest that in the general adult population, HBP is consistently lower than OBP across all the decades, but their difference might vary between age groups. Further research is needed to confirm these findings in younger and older subjects and in hypertensive individuals.

How peptide technology has improved costs and outcomes in patients with heart failure

ABSTRACT Introduction: Heart failure (HF) is characterized by substantial health and economic burden, mainly attributed to increased hospitalizations and readmissions. Its diagnosis remains challenging due to the non-specific nature of the initial symptoms of the disease. Recently, scientific evidence has highlighted the potential of natriuretic peptides (NP) in improving the diagnosis and prognosis of HF and, by extension, in restraining healthcare costs. The present review aimed at providing evidence of their optimal use in terms of economic and health outcomes. Areas covered: Systematic literature research limited to studies published from February 2006 to February 2016 was performed with the aim of identifying and analyzing all cost-effectiveness and other economic evaluation studies that investigated the economic and health outcomes of NPs use as screening and management tools for HF. Expert commentary: NP testing either added in the standard of care, or substituting frequently used diagnostic procedures for the diagnosis and management of HF, regardless of the healthcare setting of interest, was proved to be a valid tool for clinical decision-making. Moreover it was associated with improved patient outcomes and important cost-savings mainly attributed to lower admission and readmission rates, shorter hospitalization length and improved health-related quality of life.

[BP.02.03] ACCURACY OF AUTOMATED BLOOD PRESSURE MONITORS IN CHILDREN: A SYSTEMATIC REVIEW

Objective: For the accurate diagnosis of hypertension in children current guidelines recommend the use of out-of-office blood pressure (BP) monitoring, which is based almost exclusively on automated BP monitors. This study reviewed the evidence on the accuracy of automated BP monitors in children. Design and method: A systematic review of validation studies of electronic BP monitors in children (age 3–12 years) according to established validation protocols was performed. Medline and EMBASE databases were searched via Dialog ProQuest. Results: The initial literature search retrieved 4,156 articles and 28 were analyzed (31 validation studies of 29 devices; n = 3,067 including 1,450 children). 13 articles (42%) were published a decade ago or longer. Sixteen studies (52%) included children and also adolescents and 5 (16%) also adults. 11 studies that included children and older subjects did not report the number of children. From the 29 devices validated, 16 (55%) were designed for professional office BP measurement, 7 (24%) for ambulatory BP monitoring and 6 (21%) for home monitoring. Fourteen studies (45%) applied validation criteria of more than one protocols. The Association for the Advancement of Medical Instrumentation and/or International Organization for Standardization protocol was used in 20 studies (65%), the British Hypertension Society protocol in 18 (58%) and the European Society of Hypertension International protocol in 6 (19%). Korotkov K5 was used for reference diastolic BP in 14 studies, K4 in one study, and 4 studies used K4 or K5 depending on the subject (not reported in 12 studies). Results from children were reported together with those of older subjects (adolescents or adolescents and adults) in 26 studies (84%). Twenty-two studies (71%) passed the validation protocol requirements, and 9 (29%) failed (6 for systolic and diastolic BP, and 3 for diastolic only). Conclusions: The published evidence on the accuracy of electronic BP monitors in children is limited and with considerable heterogeneity. There is need for: (i) more automated devices to be tested in children; (ii) a universal protocol that meets the specific issues of children to be developed, (ii) the review process for publishing validation studies to follow a detailed checklist.

Cost-effectiveness of Ingenol Mebutate Gel for the Treatment of Actinic Keratosis in Greece

PURPOSE The present study aimed to perform a cost-effectiveness analysis of ingenol mebutate (IM) versus other topical alternatives for the treatment of actinic keratosis (AK). METHODS The analysis used a decision tree to calculate the clinical effects and costs of AK first-line treatments, IM (2-3 days), diclofenac 3% (for 8 or 12 weeks), imiquimod 5% (for 4 or 8 weeks), during a 24-month horizon, using discrete intervals of 6 months. A hypothetical cohort of immunocompetent adult patients with clinically confirmed AK on the face and scalp or trunk and extremities was considered. Clinical data on the relative efficacy were obtained from a network meta-analysis. Inputs concerning resource use derived from an expert panel. All costs were calculated from a Greek third-party payer perspective. FINDINGS IM 0.015% and 0.05% were both cost-effective compared with diclofenac and below a willingness-to-pay threshold of €30,000 per quality-adjusted life-year (QALY) (€199 and €167 per QALY, respectively). Comparing IM on the face and scalp AK lesions for 3 days versus imiquimod for 4 weeks resulted in an incremental cost-effectiveness ratio of €10,868 per QALY. IM was dominant during the 8-week imiquimod period. IM use on the trunk and extremities compared with diclofenac (8 or 12 weeks) led to incremental cost-effectiveness ratios estimated at €1584 and €1316 per QALY accordingly. Results remained robust to deterministic and probabilistic sensitivity analyses. IMPLICATIONS From a social insurance perspective in Greece, IM 0.015% and IM 0.05% could be the most cost-effective first-line topical field treatment options in all cases for AK treatment.

Home Blood Pressure Measurements

In the last decades home blood pressure monitoring (HBPM) has established its role as a valuable tool in the diagnosis and long-term management of hypertension. Main advantages are its diagnostic value in identifying white-coat and masked hypertension, its reproducibility, wide availability, good acceptance by patients and relatively low cost, which justify its widespread implementation in clinical practice. HBPM is superior to the conventional office blood pressure measurements and as good as 24 h ambulatory blood pressure monitoring in terms of association with several indices of preclinical target organ damage, including echocardiographic left ventricular index, urinary albumin excretion rate, glomerular filtration rate, carotid intima-media thickness and pulse wave velocity, as well as in predicting cardiovascular morbidity and mortality. In order to obtain the benefits of HBPM, the method should be applied under medical supervision and using validated electronic upper arm devices with automated memory or a tele-monitoring system and standard monitoring schedule as recommended by current guidelines.