At present, clinic blood pressure (BP) evaluation is being increasingly complemented by ambulatory BP measurements for the evaluation of haemodynamic patterns during daily activities and sleep. Nondipping pattern, a measure of decreased attenuation of nighttime over daytime BP, has been correlated with enhanced target organ damage and adverse cardiovascular (CV) outcomes in different clinical settings beyond pure hypertensive cohorts. As the nondipping pattern is a derivative extract of both daytime and nighttime BP, it is yet questionable whether the crude estimate of nocturnal BP is superior to daytime BP and nondipping pattern in the prediction of subclinical damage and CV events. In this review, we aimed at comparing the CV predictive value of the nondipping pattern with that of nocturnal BP using cross-sectional and longitudinal data obtained from different cohort studies within the past 10 years. Our findings suggest that nocturnal BP including the phenotype of isolated nocturnal hypertension is better associated with CV target organ damage and 'hard end points' as compared with the nondipping pattern.

Oscillometric devices are being widely used for ambulatory, home and office blood pressure (BP) measurement, and several of them have been validated using established protocols. This cross-sectional study assessed the impact on antihypertensive treatment decisions of replacing the mercury sphygmomanometer by a validated oscillometric device. Consecutive subjects attending a hypertension clinic had triplicate simultaneous same-arm BP measurements using a mercury sphygmomanometer and a validated professional oscillometric device. For each device, uncontrolled hypertension was defined as average BP ≥140/90 mm Hg (systolic/diastolic). A total of 5108 simultaneous BP measurements were obtained from 763 subjects in 1717 clinic visits. In 24% of all visits, the mercury and the oscillometric BP measurements led to different conclusion regarding the diagnosis of uncontrolled hypertension. In 4.9% of the visits, the diagnostic disagreement was considered as 'clinically important' (BP exceeding the diagnostic threshold by >5 mm Hg). These data suggest that the replacement of the mercury sphygmomanometer by a validated professional oscillometric device will result into different treatment decisions in about 5% of the cases. Therefore, and because of the known problems when using mercury devices and the auscultatory technique in clinical practise, the oscillometric devices are regarded as reliable alternatives to the mercury sphygmomanometer for office use.

There is an increasing interest in pediatric hypertension, the prevalence of which is rising in parallel with the obesity epidemic. Traditionally the assessment of hypertension in children has relied on office blood pressure (BP) measurements by the physician. However, as in adults, office BP might be misleading in children mainly due to the white coat and masked hypertension phenomena. Thus, out-of-office BP assessment, using ambulatory or home monitoring, has gained ground for the accurate diagnosis of hypertension and decision-making. Ambulatory monitoring is regarded as indispensable for the evaluation of pediatric hypertension. Preliminary data support the usefulness of home monitoring, yet more evidence is needed. Office, ambulatory and home BP normalcy tables providing thresholds for diagnosis have been published and should be used for the assessment of elevated BP in children.

Arterial stiffness, assessed by carotid-femoral pulse wave velocity (PWV) or indirectly by pulse pressure (PP) or ambulatory arterial stiffness index (AASI), is an independent predictor of cardiovascular disease in adults. However, in children limited evidence is available. This study investigated the usefulness of AASI and PP as indices of arterial stiffness in children and adolescents, by taking PWV as the reference method. Eighty-two children and adolescents (mean age 13.1±2.9 years) had 24-h ambulatory blood pressure (ABP) monitoring, PWV measurement and echocardiography. Compared with normotensives, subjects with hypertension (n=16) had higher 24-h ABP, 24-h PP and PWV, but not AASI. 24-h, PP was strongly correlated with age, weight, height, 24-h systolic ABP, PWV, left ventricular mass (LVM), LVM index, stroke volume and inversely with 24-h heart rate. AASI was also correlated with weight, height, systolic ABP and LVM, yet these associations were weaker than those of PP, and no significant correlations were found with PWV or LVM index. Moreover, closer agreement of PWV was observed with 24-h PP (71%, kappa 0.21) than with 24-h AASI (61%, kappa -0.06) in detecting subjects at the top quartile of the respective distributions. In children and adolescents, 24-h PP compared with AASI appears to be more closely associated with: (i) arterial stiffness assessed by PWV; (ii) target organ damage assessed by LVM index; and (iii) the presence of essential hypertension. These data suggest that the usefulness of AASI as an index of arterial stiffness in the pediatric population is questionable.

Cardiovascular disease (CVD) is the most common cause of death in industrialized nations. Type 2 diabetes is a CVD risk factor that confers risk similar to a previous myocardial infarction in an individual who does not have diabetes. In addition, the most common cause of chronic kidney disease (CKD) is diabetes. Together, diabetes and hypertension account for more than two-thirds of CVD risk, and other risk factors such as dyslipidemia contribute to the remainder of CVD risk. CKD, particularly with presence of significant albuminuria, should be considered an additional cardiovascular risk factor. There is no consensus on how to assess and stratify risk for patients with kidney disease across subspecialties that commonly treat such patients. This paper summarizes the results of a consensus conference utilizing a patient case to discuss the integrated management of hypertension, kidney disease, dyslipidemia, diabetes, and heart failure across disciplines.

Cost-containment measures in healthcare provision include the implementation of therapeutic and generic drug substitution strategies in patients whose condition is already well controlled with pharmacotherapy. Treatment for hypertension is frequently targeted for such measures. However, drug acquisition costs are only part of the cost-effectiveness equation, and a variety of other factors need to be taken into account when assessing the impact of switching antihypertensives. From the clinical perspective, considerations include maintenance of an appropriate medication dose during the switching process; drug equivalence in terms of clinical effectiveness; and safety issues, including the diverse adverse-event profiles of available alternative drugs, differences in the 'inactive' components of drug formulations and the quality of generic formulations. Patients' adherence to and persistence with therapy may be negatively influenced by switching, which will also impact on treatment effectiveness. From the economic perspective, the costs that are likely to be incurred by switching antihypertensives include those for additional clinic visits and laboratory tests, and for hospitalization if required to address problems arising from adverse events or poorly controlled hypertension. Indirect costs and the impact on patients' quality of life also require assessment. Substitution strategies for antihypertensives have not been tested in large outcome trials and there is little available clinical or economic evidence on which to base decisions to switch drugs. Although the cost of treatment should always be considered, careful assessment of the human and economic costs and benefits of antihypertensive drug substitution is required before this practice is recommended.

The aim of this study is to assess the effect of hospital admission on 24-h ambulatory blood pressure (ABP) in hypertensive subjects. Treated or untreated hypertensive adults with open-angle glaucoma underwent inpatient and outpatient 24-h ABP monitoring in a random order 4 weeks apart. Awake ambulatory hours, awake in-bed hours and sleep hours were reported by participants. The nighttime-to-daytime ABP dip (%) and the sleeping-to-awake dip (ambulatory and in-bed) were determined using the two ABP recordings. A total of 40 subjects were analyzed (mean age 65.7 ± 8.4 (s.d.) years, n=19 men). Daytime systolic BP (SBP) was lower in the hospital than in the outpatient setting (mean difference 4.3 ± 10.4 mm Hg, P=0.01), as was the awake ambulatory SBP (mean difference 5.0 ± 11.1 mm Hg, P=0.008). No differences were detected in 24 h, nighttime or sleeping SBP or in any of the respective diastolic outpatient vs. inpatient ABP measurements. The nighttime SBP dip (vs. daytime) was larger in the outpatient setting (8.9 ± 7.5% and 5.2 ± 4.7%, respectively; P=0.003). Sleeping SBP dip (vs. awake ambulatory and awake in-bed) was also larger in the outpatient setting (11.1 ± 7.3 and 7.8 ± 5.9%, respectively; P=0.02) with no difference in diastolic ABP. These data suggest that inpatient 24-h ABP monitoring does not reflect the usual BP level during routine daily life, nor does it represent the usual diurnal pattern of an individual. Relying on the 24-h ABP monitoring performed in the hospital environment may lead to an underestimation of ABP and an overdiagnosis of non-dippers. Therefore, 24-h ABP monitoring for decision making regarding diagnosis and treatment of hypertension should be performed only in the routine daily conditions of each individual.

Hypertension in children and adolescents has been gaining ground in cardiovascular medicine, mainly due to the advances made in several areas of pathophysiological and clinical research. These guidelines arose from the consensus reached by specialists in the detection and control of hypertension in children and adolescents. Furthermore, these guidelines are a compendium of scientific data and the extensive clinical experience it contains represents the most complete information that doctors, nurses and families should take into account when making decisions. These guidelines, which stress the importance of hypertension in children and adolescents, and its contribution to the current epidemic of cardiovascular disease, should act as a stimulus for governments to develop a global effort for the early detection and suitable treatment of high pressure in children and adolescents. J Hypertens 27:1719-1742 Q 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins.

In children and adolescents, the diagnosis of hypertension is based on office, home and ambulatory blood pressure (BP) measurements. Different normalcy tables for each method have provided 95th percentiles of BP as thresholds for hypertension diagnosis. This study assessed the differences in BP thresholds among these methods when applied in the pediatric population. The most widely used office, home and ambulatory BP normalcy tables were compared in terms of the 50th and 95th percentiles by gender and age. The range of office BP change with increasing age is wider than for home or ambulatory BP in boys and girls, apart from systolic BP in boys. Percentiles of home BP are consistently lower than that of daytime ambulatory BP. There is a trend for office BP to be lower than home or daytime ambulatory BP in the younger age subgroups. This difference is progressively eliminated with increasing age, apart from systolic BP in boys. In conclusion, in children and adolescents, the relationship between office, home and ambulatory BP thresholds provided by the widely used normalcy tables is not the same as in the adults. These findings should be taken into account when evaluating BP measurements in children and adolescents in clinical practice.

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.

Ambulatory arterial stiffness index (AASI) is a novel index derived from the linear relationship between 24-h ambulatory systolic and diastolic blood pressure (BP) measurements. This study investigated whether 'home arterial stiffness index' (HASI) based on self-home BP measurements is similar to AASI. A total of 483 hypertensive subjects underwent 24-h ambulatory and 6-day home BP monitoring. AASI and HASI were defined as one minus the respective regression slope of diastolic on systolic BP. Mean HASI (0.66+/-0.17) was higher than 24-h (0.33+/-0.15) daytime (0.50+/-0.18) and nighttime AASI (0.37+/-0.19, P<0.001 for all comparisons vs. HASI) and was weakly correlated with 24-h (r=0.14, P<0.01) daytime (r=0.14, P<0.01) and nighttime AASI (r=0.09, P=0.05). Compared to 24-h AASI, HASI was less closely associated with age (r=0.46 and 0.10 respectively, P<0.001 for difference), systolic home BP (r=0.30 and 0.09, P<0.001) and pulse pressure (r=0.52 and 0.20, P<0.001), as well as with 24-h ambulatory systolic BP (r=0.21 and 0.05, P<0.05) and pulse pressure (r=0.56 and 0.25, P<0.001). No satisfactory agreement was observed between HASI and 24-h (agreement 63%, kappa 0.02) daytime (agreement 65%, kappa 0.1) or nighttime AASI (agreement 63%, kappa 0.03) in detecting subjects at the top quartile of the respective distributions. HASI appears to be similar but also has important differences from AASI and is less closely associated with markers of arterial stiffness. These data do not support the view that home BP measurements can replace ambulatory monitoring in the assessment of the arterial stiffness index.