In type 1 diabetes, the risk of nephropathy is strongly influenced by the level of blood pressure (BP). Ambulatory BP (ABP) monitoring has revealed an association between disturbed nocturnal BP drop and albuminuria and suggested a role of BP in microalbuminuria development. This study investigated the relationship between the urinary albumin excretion ratio (AER) and home BP (HBP) compared with ABP and clinical BP (CBP) measurements. A total of 50 adolescents and young adults with type 1 diabetes without hypertension or overt proteinuria (mean age 20+/-3.8 (s.d.) years, 21 male) had measurements of CBP (3 visits), HBP (6 days), 24-h ABP and AER (daytime and nighttime in the same 24 h with ABP monitoring). AER of 24 h was correlated with systolic 24-h (r=0.31), daytime (r=0.33) and nighttime ABP (r=0.36), without significant correlation with diastolic ABP, CBP or HBP (systolic or diastolic). Nighttime AER was correlated with 24-h (r=0.39/0.35, systolic/diastolic), daytime (r=0.36/0.32) and nighttime ABP (r=0.44/0.28). HBP was not associated with nighttime AER, but CBP was (diastolic BP only, r=0.41). No significant correlations were found between daytime AER and BP measurements. The nocturnal BP dip was not associated with any BP value. In non-dippers, nighttime AER showed strong correlations with ABP (24-h: r=0.45/0.42, systolic/diastolic; daytime: r=0.46/0.45; nighttime: r=0.49/0.35), HBP (r=0.34/0.31) and CBP (r=0.39/0.47). No such associations were found in dippers (r=0.05-0.10). These preliminary data suggest that in the early stage of diabetes-1, 24-h ABP monitoring seems to be the optimal method of revealing the association between BP and albuminuria, and cannot be replaced by HBP monitoring.

Oscillometric devices are being widely used for ambulatory, home and office blood pressure (BP) measurement. However, even successfully validated oscillometric devices fail to provide accurate measurements in some patients. This study investigated the prevalence, the reproducibility and the characteristics of the phenomenon of unreliable oscillometric BP (UOBP) measurement. A total of 5070 BP measurements were obtained simultaneously (Y connector) using a professional oscillometric device (BpTRU) and a mercury sphygmomanometer in 755 patients (1706 visits). UOBP readings were defined as those with >10 mm Hg difference (systolic or diastolic) between the two methods. UOBP was found in 15% of systolic and 6.4% of diastolic BP measurements. In all, 18% of the participants had UOBP in their first but not their second visit, or the reverse. However, 49% of these participants had at least one more UOBP visit after their second visit within the study database. Patients with persistent UOBP were more likely to be female and had lower arm circumference. The systolic BP discrepancy between the two methods was associated with pulse pressure (r=0.41) and inversely with diastolic BP (r=0.40) and arm circumference (r=0.30), whereas the diastolic discrepancy with diastolic BP (r=0.61) and inversely with pulse pressure (r=0.32). There was a consistent significant trend for larger systolic BP discrepancy and smaller diastolic from the lower to the higher pulse pressure quintile (P<0.0001). A decreasing arm circumference was a significant predictor of persistent UOBP. These data suggest that the UOBP measurement is particularly common, not very reproducible and mainly affected by pulse pressure and arm circumference.

Atrial fibrillation (AF) is the most common sustained arrhythmia and is associated with an increased long-term risk of stroke. A screening test for early diagnosis has the potential to prevent AF-related strokes. This study assessed the diagnostic accuracy of an automated device for self-home blood pressure (BP) monitoring, which implements an algorithm for AF detection. A modified, automated oscillometric device for self-home BP monitoring (Microlife BPA100 Plus, Microlife, Heerbrugg, Switzerland) with an AF detector was used to carry out triplicate BP measurements in subjects with sinus rhythm, AF and non-AF arrhythmias. During each BP measurement, the electrocardiogram (ECG) was recorded simultaneously. A total of 217 simultaneous BP measurements and ECG recordings were obtained from 73 subjects. Twenty-seven subjects (37%) had AF, 23 (31%) non-AF arrhythmias and 23 (31%) had sinus rhythm. A single measurement had 93% sensitivity and 89% specificity for detecting AF. For two measurements, in which one of them was required to detect AF, the sensitivity was 100% and specificity 76%, whereas for three measurements, in which two of them were required to detect AF, the sensitivity was 100% and specificity 89% (kappa=0.86 for an agreement with ECG). Using the latter approach, there were five false positive cases all having irregularities in approximately 50% of the heartbeats. In patients with tachyarrhythmia, the device underestimated heart rate. These data suggest that an electronic device for self-home BP monitoring, which implements an algorithm for AF diagnosis has an excellent diagnostic accuracy and might, therefore, be used as a reliable screening test for the early diagnosis.

This study compared the long-term reproducibility of home blood pressure (BP) in comparison with office BP in children and adolescents. Forty-eight subjects (27 boys, mean age 11.3+/-3.1 (s.d.) years) recruited from the Arsakeion school study because of elevated office and/or home BP were assessed with office (1 visit, mercury sphygmomanometer) and home BP measurements (3 days, electronic devices) in two assessments 17+/-4.9 months apart (range 10-26 months). Home and office BP were compared on the basis of the following criteria: (a) s.d. of mean BP; (b) s.d. of differences; (c) variation coefficient (CV); (d) concordance correlation coefficient (CCC); (e) test-retest correlations; (f) correlation with ambulatory BP. (a) The s.d. of mean home BP was lower than that of office BP in both the initial (home BP 9.1/7.1 mm Hg, systolic/diastolic; office BP 13.1/8.0 mm Hg) and the second assessment (9.2/6.0 and 14.9/11.5 respectively). (b) The s.d. of differences was lower for home BP (8.3/6.5 mm Hg, systolic/diastolic) than for office BP (13.9/10.7 mm Hg). (c) The CV of home BP (5.3/6.6, systolic/diastolic) was lower than that of office BP (8.2/10.9). (d) The CCC of home BP (0.54/0.50, systolic/diastolic) was higher than that of office BP (0.51/0.41). (e) Test-retest correlations were closer for home BP (r=0.58/0.52, systolic/diastolic) than for office BP (0.51/0.44). (f) Awake ambulatory BP was more closely associated with home (r=0.77/0.40, systolic/diastolic) than with office BP (0.65/0.24). These data suggest that in children and adolescents the long-term reproducibility of home BP is superior to that of office measurements.

A school-based screening with anthropometric and blood pressure (BP) measurements was performed in adolescents aged 12-17 years in the island of Samos, Greece, in 2004 and also in 2007. A total of 446 adolescents were included in the analysis in 2004 and 558 in 2007. The 2007 study population had higher levels of body mass index (BMI) (P<0.05) and systolic and diastolic BP (P<0.001), compared with 2004. The prevalence of high BP was 16.1% in 2004 and 22.9% in 2007 (P<0.01 for difference). Mean age-, sex- and BMI-adjusted BP increase was 4.1/10.5 mm Hg (systolic/diastolic). In multivariate analysis, BMI, male gender and age, but also modifiable factors (lack of physical activity, breakfast skipping, smoking and low milk consumption) were associated with increased BP levels in the study population. These data indicate that further to BMI, other factors such as adverse lifestyle and dietary habits appear to be associated with elevated BP levels in adolescents. Moreover, rising trends seem to characterize the prevalence of high BP.

The blood pressure (BP) waveform varies substantially between the peripheral conduit (brachial) and the central elastic (aorta) arteries mainly do a gradual increase of systolic BP, as the wave propagates distally. This phenomenon is called BP amplification and is principally generated by the presence of arterial stiffness gradient and wave reflections along the arterial bed. More and more clinical studies suggest that central BP may provide additional information regarding cardiovascular risk beyond peripheral BP. Arterial properties and thus pressure amplification, are modulated by age, cardiovascular risk factors, vasoactive substances and drugs. Recent evidence suggests, beyond any doubt, that antihypertensive drugs affect peripheral and central BP differentially and alter pressure amplification. The aim of the present review (Part II) is to summarize the available evidence regarding: (i) the specific class-effect of antihypertensive drugs on central BP beyond peripheral BP, as well as the potential underlying hemodynamic mechanisms, (ii) head to head comparison of the effect of different classes of antihypertensive drugs on central BP, (iii) the effect of combination drug treatment on central BP. Finally to attempt an interpretation of the clinical trials in hypertension, which classically record brachial BP, based on the results of studies which assessed central BP. Several conclusions were drawn. First, it is clear that there are important differences between the classes of antihypertensive drugs regarding their effects on BP amplification. Second, it seems that the newer antihypertensive drugs [angiotensin converting enzyme inhibitors (ACEIs), angiotensin receptor blockers and dihydropyridine calcium blockers], as well as nitrates, have a more beneficial effect on BP amplification than the older drugs (diuretics and BBs). Third, there is compelling evidence regarding the detrimental effect of BBs (mainly atenolol) on central BBs and convincing evidence that ACEIs increase BP amplification.

Obesity is related to office blood pressure (OBP). Important discrepancies exist between OBP and home blood pressure (HBP), providing complementary information for the management of hypertension. The association between obesity and HBP has not been investigated in children. The evidence on the role of obesity in the predominance of systolic blood pressure (SBP) over diastolic (DBP) in paediatric hypertension is limited. A total of 778 healthy subjects aged 6-18 years were recruited in this study. OBP and HBP were measured using electronic devices validated in children. Anthropometric measurements were measured and expressed as z-scores for height or age. Among all indices of obesity (z-scores), body mass index (BMI) showed the best association with BP. The effect of obesity (BMI) was more pronounced on: (i) SBP than DBP and (ii) H-SBP than O-SBP (O-SBP: r2=0.09, O-DBP: r2=0.05, H-SBP: r2=0.12, H-DBP: r2=0.06). The prevalence of systolic hypertension was higher than that of diastolic hypertension. This difference was significant only in office readings and independent from obesity (normal weight: 6.3% systolic hypertension versus 1.2% diastolic; obese: 37.9% versus 6.9%, P<0.05 for both). These data imply that in children and adolescents the z-score of BMI is the most appropriate index of the association between BP and obesity. It also suggests that obesity is probably more closely associated with home than office BP. Finally, although obesity appears to affect SBP more than DBP, these results suggest that the predominance of systolic hypertension in children and adolescents might not be only related to obesity but also to the measurement setting (office).

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.