The surge in blood pressure (BP) upon rising after waking in the morning has been associated with increased risk of target organ damage and cardiovascular events. The reproducibility of this phenomenon within the same 24-h period was tested in subjects with a siesta during ambulatory BP monitoring by assessing the morning surge (MS) vs. the evening surge (ES) after siesta. Ambulatory BP recordings with reported siesta from hypertensive subjects were analyzed. MS and ES were assessed using four different definitions. The intraindividual reproducibility was assessed using the standard deviation of differences between MS and ES, the concordance correlation coefficient, the coefficient of variation and the agreement between MS and ES in detecting "surgers" among hypertensive subjects (top quartile of the BP surge distribution). A total of 562 ambulatory recordings were analyzed (476 subjects, mean age 54.9+/-13.2 [SD] years, treated 47%). Average MS (16.3/14.4 mmHg, systolic/diastolic) was higher than ES (13.3/12.1 mmHg, p<0.001) due to higher post-rising BP in the morning (p<0.01). The intraindividual reproducibility was rather poor, with no clear differences among different definitions. However, there was about 70% agreement between MS and ES in the detection of "surgers" (systolic and diastolic, kappa statistic 0.18). These data suggest that, although the intraindividual reproducibility of the BP surge within the same 24-h period is rather poor, about 70% of the "morning surgers" were also "evening surgers." Thus, the BP surge might be an inherent pathophysiological characteristic of the BP behavior of an individual and deserves further investigation.

Preliminary evidence suggests that the morning surge (MS) in blood pressure (BP) is an independent predictor of cerebrovascular disease. However, the optimal definition of MS is uncertain. To compare the reproducibility of several MS definitions used in the literature, 132 untreated hypertensives were assessed with ambulatory BP monitoring twice, 2 weeks apart. Five MS definitions were compared. MS-1: the average BP of the first hour after rising minus the average BP of the first hour before rising; MS-2: BP 2 h after rising minus that of 2 h before rising; MS-3: BP 3 h after rising minus that of 3 h before rising; MS-4: BP 2 h after rising minus the average BP during sleep; MS-5: BP 2 h after rising minus the average BP of 3 consecutive readings, centered on the lowest reading during sleep. The reproducibility of each MS definition was assessed using the concordance correlation coefficient (CCC), the standard deviation of differences (SDD) and the coefficient of variation (CV) between repeated MS assessments, and the agreement in detecting "surgers," defined as subjects at the top quartile (Q4) of the MS distribution. CCCs were 0.20/0.30, 0.43/0.45, 0.53/0.51, 0.51/0.47, and 0.46/0.48 (systolic/diastolic) for MS-1 to MS-5 respectively; SDDs were 14.3/11.4, 12.1/9.9, 11.2/9.5, 10.3/8.2, and 11.9/9.8, respectively; CVs were 0.49/0.57, 0.44/0.39, 0.37/0.35, 0.36/0.31, and 0.27/0.24, respectively; and the agreement in detecting "surgers" was 69%/70%, 71%/76%, 75%/75%, 81%/83%, and 74%/75%, with kappa of 0.18/0.20, 0.23/0.36, 0.33/0.33, 0.49/0.53 and 0.29/0.31, respectively. There are important differences in the reproducibility of MS calculated by different methods. MS4 appears to provide the most reproducible definition of MS.

Carotid-femoral pulse wave velocity (PWV), an integrated marker of segmental aortic stiffness, was recently proposed as one of the underlying mechanisms inducing orthostatic hypotension in the elderly with marked arterial rigidity. We examined the relationship between PWV (Complior; Colson, Paris, France) and orthostatic blood pressure (BP) changes, measured repeatedly, over a wide range of age and arterial stiffness. Sixty-nine hypertensive subjects (age, 37 to 76 years; 39 untreated and 30 treated) were studied. BP, in both sitting and erect position, was measured at two occasions a few weeks apart, and in between PWV was assessed by means of pulse wave analysis. In untreated hypertensive subjects, the orthostatic alterations in systolic, but not in diastolic blood pressure (DBP), were inversely related to PWV, independently from age, gender, mean BP, and diabetes mellitus. The greater the aortic stiffness the larger was the systolic blood pressure (SBP) decrease during upraises. On the contrary, no such association was found between PWV and orthostatic changes of BP in treated hypertensive subjects. These results suggest the presence of a pathophysiological association between arterial stiffening and BP postural changes. Antihypertensive drug treatment, as well as other factors that have not been evaluated in the present study, might have modulated this association. However, it might be argued that a causal association between arterial stiffness - disturbed baroreflex sensitivity - postural BP changes, even in subjects without pronounced vascular aging or orthostatic hypotension, is implied.

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.

An appropriate cuff according to the individual's arm circumference is recommended with all blood pressure (BP) monitors. An electronic device for home monitoring has been developed (Visomat Comfort 20/40) that estimates the individual's arm circumference by measuring the cuff filing volume and makes an adjustment of measured BP taking into account the estimated arm circumference. Thus the manufacturer recommends the use of a single cuff for arm circumference 23-43 cm. The device accuracy was assessed using the European Society of Hypertension International Protocol. Simultaneous BP measurements were obtained in 33 adults by two observers (connected mercury sphygmomanometers) four times, sequentially with three measurements taken using the tested device. Absolute device-observer BP differences were classified into < or =5, < or =10 and < or =15 mm Hg zones. For each participant the number of measurements with a difference < or =5 mm Hg was calculated. The device produced 60/89/97 measurements within 5/10/15 mm Hg respectively for systolic BP, and 72/97/98 for diastolic. Twenty-three subjects had at least two of their systolic BP differences < or =5 mm Hg and three had no differences < or =5 mm Hg (for diastolic 27 and 1, respectively). Mean device-observer BP difference (systolic/diastolic) was 3.7 +/- 5.6/-1.5 +/- 4.7 mm Hg (4.7 +/- 4.9/ - 1.7 +/- 4.3 in arm circumference 23-29 cm [39 readings] and 3.1 +/- 5.9/-1.4 +/- 5.0 in arm 30-34 cm [60 readings], P=NS). In conclusion, the device fulfils the International Protocol requirements and can be recommended for clinical use. Interestingly, the device was accurate using a single cuff in a wide range of arm circumference (23-34 cm). This study provides no information about the device accuracy in larger arms.

Propagation of odontogenic masticator space abscesses is insufficiently understood. The purpose was to analyse pathways of spread in 30 patients with odontogenic masticator space abscess. The imaging findings in 30 patients (CT in 30, MR in 16 patients) were retrospectively analysed. CT and MR imaging depicted a masticator space abscess within: medial pterygoid muscle in 13 patients (43.3%), lateral masseter and/or pterygoid muscle in 14 (46.7%) and superficial temporal muscle in 3 patients (10%). In the lateral masticator space intra-spatial abscess extension occurred in 7 of 14 patients (50%). The sub-masseteric space provided a pathway in seven (70%). Extra-spatial extension involved the submandibular space only in 3 of 14 patients (21.4%). Medial masticator space abscesses exhibited extra-spatial spread only. Extension affected the parapharyngeal space and/or soft palate in 7 of 13 lesions (53.8%). MR imaging in comparison to CT increased the number of abscess locations from 18 to 23 (27.8%) and regions affected by a cellular infiltrate from 12 to 16 (33.3%). The sub-masseteric space served as a previously underestimated pathway for intra-spatial propagation of lateral masticator abscesses. Medial masticator space abscesses tend to display early extra-spatial parapharyngeal space and/or soft palate extension.

Although self-monitoring of blood pressure by patients at home is being widely used in clinical practice, the evidence on its prognostic value is still limited. Five long-term studies with nearly 60,000 patients/year have provided prognostic information for home blood pressure measurements. Differences exist among these studies regarding the population characteristics, the sample size and follow-up, the methodology and protocol for office and home blood pressure measurement and the adjustment procedure for other risk factors. All these studies, nevertheless, showed systolic home blood pressure to be a significant predictor of cardiovascular risk, and three of them also showed prognostic value of diastolic home blood pressure. Moreover, the prognostic value of home blood pressure appeared to be consistently superior to that of conventional office measurements. The prognostic significance of the white coat and the masked hypertension phenomena detected by home measurements were investigated in two studies, one in treated hypertensive patients and another in a general population sample. These studies showed that patients with white-coat phenomenon have similar cardiovascular risk as those with low office and home blood pressure, whereas the masked hypertension phenomenon is associated with high risk as in patients with uncontrolled hypertension. In conclusion, the available evidence suggests that home blood pressure has strong prognostic value, which appears to be superior to that of the conventional office measurements. More outcome studies on the prognostic value of home blood pressure, however, are needed.

The random variation of BP and the intraindividual variation in the BP response to treatment cause considerable difficulties in the evaluation of the dose-response relationship of antihypertensive drugs. Thus, failures in finding the optimal dose of antihypertensive drugs have not been uncommon. The notion that angiotensin receptor antagonists (angiotensin receptor blockers) have a relatively flat dose-response relationship also appears to be due to limitations of dose-finding studies. The conventional method of office BP measurement that is typically used in dose-finding studies is poorly reproducible and is subject to the white coat effect, placebo effect, and observer bias. These problems can be overcome by using ambulatory or home BP monitoring, which are known to improve the accuracy of studies aiming to detect BP changes. A crossover design study allows all participants to receive all treatments (doses) and paired comparisons are performed. Thus, this design significantly enhances the power to detect differences between doses, compared with the typical parallel-group dose-finding study. A separate analysis of the dose-response relationship exclusively in subjects with a good BP response to the drug (responders) can provide clear insight about the drug effect when it actually works. These measures improve the accuracy of drug trials investigating the dose-response relationship and might prevent misleading information at an early stage of clinical development.

The optimal schedule for home blood pressure monitoring should represent the usual level of home blood pressure, give a reproducible value, and have prognostic ability. Therefore, outcome studies, as well as short-term trials assessing the reproducibility of home blood pressure, its stability over time and its relationship with ambulatory blood pressure should be taken into account. A review of this evidence suggests that the optimal schedule should be based on 12-14 measurements, and even more measurements up to 25 are desirable. Morning and evening measurements should be obtained, with at least duplicate measurements per occasion. Measurements on the initial day should preferably be discarded.