Paul L. Padfield

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.

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.

Deficient inactivation of cortisol by 11β‐hydroxysteroid dehydrogenase in essential hypertension

OBJECTIVE 11 β‐Hydroxysteroid dehydrogenase protects renal mineralocorticoid receptors from Cortisol by converting Cortisol to inactive cortisone. 11 β‐Dehydrogenase deficiency, either congenital or after inhibition by liquorice and carbenoxolone, results in cortisol‐dependent mineralocorticoid excess and hypertension. We tested the hypothesis that the same mechanism occurs in some patients with essential hypertension.

Increased vasoconstrictor sensitivity to glucocorticoids in essential hypertension

Glucocorticoids raise blood pressure but were thought not to play a pathophysiological role in essential hypertension when it was demonstrated that cortisol secretion rates and circulating concentrations are normal in this disease. However, recent observations suggest that increased tissue sensitivity to cortisol, mediated by either abnormal glucocorticoid receptors or impaired inactivation of cortisol by 11 beta-dehydrogenase, may allow cortisol to raise blood pressure despite normal circulating concentrations. We studied 11 patients with essential hypertension and 11 matched normotensive control subjects. Dermal vasoconstriction after topical application of both cortisol (16 +/- 4 versus 32 +/- 5 U, control subjects versus hypertensive patients; P < .02) and beclomethasone dipropionate (75 +/- 10 versus 100 +/- 7 U; P < .05) was increased in the hypertensive patients. Hypothalamic-pituitary glucocorticoid receptor sensitivity was normal, as judged by basal cortisol secretion rates and suppression of plasma cortisol during sequential overnight dexamethasone suppression tests. 11 beta-Dehydrogenase activity was impaired in essential hypertension, as judged by prolonged half-lives of [11 alpha-3H]cortisol (44 +/- 4 versus 58 +/- 4 minutes, control subjects versus hypertensive patients; P < .02). However, this did not correlate with the dermal vasoconstrictor response. We conclude that vasoconstrictor sensitivity to glucocorticoids is increased in essential hypertension and that this may initiate and/or sustain the increased peripheral vascular resistance that characterizes this disease. The mechanism of increased sensitivity remains uncertain, but it will be important to establish whether it relates to genetic abnormalities of the glucocorticoid receptor that have been observed in animal models and young individuals who are predisposed to essential hypertension.

HOW EFFECTIVE IS EXTERNAL PITUITARY IRRADIATION FOR GROWTH HORMONE‐SECRETING PITUITARY TUMOURS?

Forty‐six patients with GH‐secreting pituitary tumours were treated with conventional external pituitary irradiation through two opposed fields to a total dose of 3750 cGy over 15 fractions. Thirty‐patients received external radiotherapy as primary treatment and 16 received radiotherapy combined with pituitary surgery. The mean (± SD) serum GH in the former group was 74.3 ± 74.8 mU/1 before treatment, falling by 28% per year over 0–5 years and by 16% per year over 0–20 years. The mean (± SD) serum GH in the latter group was 265.4 ± 209.3 mU/1 before treatment, falling by 76% in the first year—a direct result of surgical removal of tumour—then by 30% per year over 1–5 years and 16% per year over 1–20 years. Progressive failure of normal anterior pituitary function developed by 10 years, with variable loss of gonadotrophin, corticotrophin and thyrotrophin function. The respective figures for patients treated with radiotherapy alone were 47.4, 29.6 and 16.0% and for the combined group were 70.2, 53.9 and 38.1%. Whilst external pituitary irradiation appears to reduce serum GH concentrations in patients with GH‐secreting pituitary tumours the major disadvantages of this form of treatment are the time taken to achieve a cure and the high incidence of hypopituitarism. Nevertheless there did not appear to be any other serious side effects.

Telemonitoring based service redesign for the management of uncontrolled hypertension: multicentre randomised controlled trial.

Objective To determine if an intervention consisting of telemonitoring and supervision by usual primary care clinicians of home self measured blood pressure and optional patient decision support leads to clinically important reductions in daytime systolic and diastolic ambulatory blood pressure in patients with uncontrolled blood pressure. Design Multicentre randomised controlled trial. Setting 20 primary care practices in south east Scotland. Participants 401 people aged 29-95 years with uncontrolled blood pressure (mean daytime ambulatory measurement ≥135/85 mm Hg but ≤210/135 mm Hg). Intervention Self measurement and transmission of blood pressure readings to a secure website for review by the attending nurse or doctor and participant, with optional automated patient decision support by text or email for six months. Main outcome measures Blinded assessment of mean daytime systolic ambulatory blood pressure six months after randomisation. Results 200 participants were randomised to the intervention and 201 to usual care; primary outcome data were available for 90% of participants (182 and 177, respectively). The mean difference in daytime systolic ambulatory blood pressure adjusted for baseline and minimisation factors between intervention and usual care was 4.3 mm Hg (95% confidence interval 2.0 to 6.5; P=0.0002) and for daytime diastolic ambulatory blood pressure was 2.3 mm Hg (0.9 to 3.6; P=0.001), with higher values in the usual care group. The intervention was associated with a mean increase of one general practitioner (95% confidence interval 0.5 to 1.6; P=0.0002) and 0.6 (0.1 to 1.0; P=0.01) practice nurse consultations during the course of the study. Conclusions Supported self monitoring by telemonitoring is an effective method for achieving clinically important reductions in blood pressure in patients with uncontrolled hypertension in primary care settings. However, it was associated with increase in use of National Health Service resources. Further research is required to determine if the reduction in blood pressure is maintained in the longer term and if the intervention is cost effective. Trial registration Current Controlled Trials ISRCTN72614272.

Effect of the insertion/deletion polymorphism of the angiotensin-converting enzyme gene on response to angiotensin-converting enzyme inhibitors in patients with heart failure

There is marked interindividual variation in serum and tissue angiotensin-converting enzyme (ACE) levels for which the insertion (I)/deletion (D) polymorphism in intron 16 of the ACE gene is a marker. ACE inhibitors have important effects on morbidity and mortality in heart failure. The influence of this polymorphism on the response to ACE inhibitors in patients with heart failure is not known. We studied response by ACE genotype of 34 subjects in a randomised, double-blind, crossover study comparing 6 weeks of lisinopril (10 mg, o.d.) or captopril (25 mg, t.d.s.) on 24-h blood pressure (BP) profile and on renal function in patients with symptomatic heart failure [mean left ventricular ejection fraction (LVEF), 24%]. Glomerular filtration rate (GFR), 99mTc diethylenetriaminepentaacetic acid (DTPA), and ambulatory 24-h mean arterial pressure (MAP; Spacelabs 90207) were assessed at the beginning and end of treatment periods. There was a significant relation between ACE genotype and change in MAP with captopril (mm Hg; DD group, -0.5; ID, -4.7; II, -7.4; p = 0.02) but not to lisinopril (mm Hg DD, -6.0; ID, -6.6; II, -7.4; p = 0.89) in these patients. There was no significant relation between genotype and change in GFR with captopril (percentage change from baseline: DD, +7.9; ID, +13.1; II, -0.6; p = 0.45) or lisinopril (percentage change from baseline: DD, -0.1; ID, -3.0; II, -13.3; p = 0.39), but the decline in renal function tended to be greatest in II subjects. Whereas the results are not conclusive, there may be a significant interaction between ACE genotype and response to ACE inhibitors in patients with heart failure.

The accuracy of automated blood pressure measuring devices in patients with controlled atrial fibrillation.

Objective To determine whether automated blood pressure measuring devices can measure blood pressure accurately in patients with atrial fibrillation. Design Comparison of the accuracy of two electronic sphygmomanometers [Takeda UA-751 (Takeda) and Copal UA-251 (Copal)] and two ambulatory blood pressure monitors [Accutracker 1 (Accutracker) and SpaceLabs 90207 (SpaceLabs)] with that of a trained observer using a Hawksley random-zero sphygmomanometer (Hawksley), using the sequential same-arm technique. Setting University teaching hospital: medical wards and outpatient department. Subjects Twenty-eight patients, mean SD age 72 ± 9 years, blood pressure range 90–158/40–96 mmHg, in atrial fibrillation with a controlled ventricular rate. Main outcome measures The proportion of machine readings > 5 mmHg different from the Hawksley reading was compared with that obtained by three sequential Hawksley measurements. The variability of each measuring method was assessed by determining the SDD for the paired readings from each device. Results Five per cent of Takeda, 5% of Copal, 14% of Accutracker and 21% of SpaceLabs readings could not be obtained. Sequential testing with the Hawksley resulted in an accuracy at the 5-mmHg level of (systolic/diastolic) 79/79%, compared with 64/54% (P<0.05 for diastolic) for the Takeda, 68/75% (NS) for the Copal, 50/36% (P < 0.01 for both) for the Accutracker and 50/29% (P < 0.01 for systolic, P < 0.001 for diastolic) for the SpaceLabs. Intrapatient variability, as assessed by SDD, was 8.3/8.6 mmHg for the Hawksley, similar to that for the Copal (7.7/7.3 mmHg) but higher for the Takeda (11.2/19.7 mmHg), the Accutracker (22.4/26.3 mmHg) and the SpaceLabs (7.5/14.8 mmHg). Conclusions Accurate measurement of blood pressure with an electronic device is possible in patients who have atrial fibrillation; the Copal UA-251 provides a satisfactory level of accuracy. However, the marked difference between devices and the limited accuracy of the other machines tested here demonstrates the need to ensure that such devices are of proven accuracy in this patient group.

Assessing the HPA axis in patients with pituitary disease: a UK survey.

Objective   Assessing the integrity of the hypothalamic–pituitary–adrenal (HPA) axis following pituitary surgery is necessary to determine the requirement for glucocorticoid replacement therapy, but there remains controversy about the optimum way to measure this.

Task force VI: Self-monitoring of the blood pressure.

BACKGROUND Self-monitoring of the blood pressure by patients at home or in other nonclinical settings has become increasingly common in recent years. This phenomenon has been fueled in part by the increase in availability of automatic sphygmomanometers, which are now both affordable and easy for patients to use. BENEFITS OF SELF-MONITORING: Self-monitoring of the blood pressure can be an important adjunct to management of hypertension. The technique allows patients to participate more in their care. Self-measured values of blood pressure are more likely to be representative of the average daily blood pressure than is a clinic measurement and may be better related to hypertensive involvement of target organs and cardiovascular morbidity than is the clinic blood pressure. Finally, the self-monitoring of blood pressure has the potential to reduce the costs of hypertension-related care. LIMITATIONS OF SELF-MONITORING: There are several issues that prevent the more widespread use of self-monitoring of the blood pressure in clinical practice. First, devices marketed for use by patients have advanced technically during the 1990s, but many have not been subjected to rigorous clinical validation for precision and reliability (e.g. in terms of Association for the Advancement of Medical Instrumentation and British Hypertension Society guidelines). It is recommended that devices for measuring blood pressure used by patients at home be subjected to the same validation processes as those that are applied to ambulatory recordings. Second, although the upper limits of normal for self-monitored blood pressure of a general population can be defined statistically (it is approximately 135/85 mmHg), it is not yet possible to determine the normal self-monitored blood pressure because these values must be linked to classical clinical cardiovascular endpoints or outcomes. Third, the relationships among self-monitored, clinic, and ambulatory blood pressures are defined for some populations but their behaviors according to age, sex, ethnicity, and treatment status require further study. Fourth, several different schedules for self-monitoring of the blood pressure by patients have been used in clinical research and practice. It will be necessary to determine the optimal schedule and number of recordings required when patients perform self-monitoring of the blood pressure. Fifth, self-monitoring of the blood pressure in clinical trials of antihypertensive therapies is certainly feasible but has typically not been included in their design, either by investigators or by the pharmaceutical sponsors. Sixth, there have been data suggesting that self-monitoring of the blood pressure reduces the comprehensive costs associated with hypertension care on an annual basis. However, since most work on the economic impact of self-monitoring of the blood pressure has been performed in managed-care environments in the USA, it is not known whether this reduction in health-care costs would be applicable to other types of practice environments on a worldwide basis. CONCLUSIONS Self-monitoring of the blood pressure is at present useful as an adjunct measurement for the management of hypertensive patients and might provide benefits in clinical trials of antihypertensive therapy. Nevertheless, the available data on self-monitoring of the blood pressure are inadequate as grounds for clinicians to make primary diagnostic or therapeutic decisions and should not override the blood pressure obtained by clinical measurement or via ambulatory monitoring.