The measurement of blood pressure remains the cornerstone for diagnosing and managing individuals with hypertension. Today there is international consensus on the optimal technology and methodology for reliable evaluation of blood pressure. Automated oscillometric upper-arm cuff blood pressure devices which have been properly validated are recommended for all measurement methods. Office blood pressure measurement remains an essential method, yet as much as possible treatment decisions should be primarily based on out-of-office blood pressure monitoring at home or with 24-hour ambulatory monitoring. It is important that established protocols are applied to standardise each of these methods in clinical practice, to exhaust their potential in diagnosing hypertension and guiding treatment-induced blood pressure decline. Despite the wide use of blood pressure measurement methods for too long time, there are still research questions regarding their optimal clinical implementation, which need to be addressed in future studies.

Carotid-femoral pulse wave velocity (cfPWV) is the reference method for measuring large artery stiffness. Automated brachial-ankle pulse wave velocity (baPWV) is an alternative method for assessing medium-to-large artery stiffness. A systematic review/meta-analysis was performed to investigate the relationship of cfPWV and baPWV measurements regarding their difference and association, and their relationship with indices of subclinical target organ damage (TOD) and cardiovascular outcomes. Among 1000 records initially retrieved, 51 were included ( n  = 36 126). Meta-analysis of 46 studies [ n  = 32 426, weighted mean age 61 years, men 49%, BMI 25.1 kg/m 2 , SBP/DBP 129/75 mmHg, hypertension 58%, diabetes 23%, smokers 17%, baPWV 15.82 m/s, cfPWV 9.47 m/s] indicated a pooled baPWV-cfPWV mean difference 5.03 m/s [95% confidence intervals (4.34-5.72)]. Meta-analysis of 23 studies ( n  = 10 880, age 58 years, men 58%, BMI 26.2 kg/m 2 , BP 126/74 mmHg, hypertension 41%, diabetes 16%, smokers 13%) indicated a pooled baPWV vs. cfPWV Pearson correlation coefficient 0.68 (0.61, 0.74). Similar correlations of baPWV/cfPWV with left ventricular mass index, carotid intima-media thickness and urine albumin-to-creatinine ratio were found. Limited data indicated a slightly higher predictive value of cfPWV for cardiovascular outcomes. Sensitivity and multivariable meta-regression analyses indicated significant associations of pooled baPWV-cfPWV mean difference with the distance used for cfPWV calculation and baPWV/cfPWV devices. baPWV and cfPWV are strongly correlated to each other and similarly to subclinical TOD, but baPWV gives higher values. There is considerable heterogeneity among the available studies and standardized design and methodology is needed in future research.

Hypertension remains a major public health challenge with inadequate control globally. The May Measurement Month (MMM) global survey initiated by the International Society of Hypertension was implemented in Greece in 2022 aiming to raise hypertension awareness and control. Adult volunteers were recruited through opportunistic screening in 11 urban areas. Information on medical history and three sitting blood pressure (BP) measurements were obtained using validated automated upper-arm devices, and the data were submitted online through a custom-designed app of the global MMM survey. Hypertension was defined as average systolic BP at least 140 mmHg and/or diastolic 90 mmHg, and/or self-reported use of drugs for hypertension. A total of 6353 individuals were included (mean age 54.8 ± 16.2 years, 49% men, 30.5% current smokers, 11.5% had diabetes, 5.1% cardiovascular disease). The prevalence of hypertension (42.6%) was higher in men (48.8%) and in older individuals (74%). Among individuals with hypertension, 27.5% were unaware of their diagnosis, 22.2% were treated but uncontrolled (≥140 mmHg systolic and/or ≥90 mmHg diastolic BP), and 47.9% were treated and controlled. Among treated hypertensives, 58.2% were on monotherapy and at least one-third of them were uncontrolled. The prevalence of hypertension in Greece seems to be high and is often undiagnosed, untreated, and uncontrolled. Public health initiatives and campaigns aiming at improving hypertension diagnosis and control need to be implemented.

Interest in the pathophysiology, measurement, and clinical implications of nocturnal blood pressure (BP) has significantly increased due to its strong association with cardiovascular risk, and its importance was recognized by the 2023 European Society of Hypertension (ESH) guidelines. Nocturnal BP regulation is complex and multifactorial, involving sleep-wake cycle, circadian rhythms, autonomic nervous system, renin-angiotensin-aldosterone system, and renal mechanisms. 24-h ambulatory blood pressure monitoring is currently the reference method for nocturnal BP assessment. Home BP monitoring, with specially designed, validated devices with nocturnal BP measuring function, may also be used, while new cuffless and wearable technologies hold great potential but require further validation. Nocturnal BP phenotypes of clinical interest include nocturnal hypertension, increased nocturnal BP variability and altered day-night BP fluctuations. Among those, isolated nocturnal hypertension may be considered a type of masked hypertension. BP variability has prognostic relevance, as do the day-night BP changes, i.e. the nocturnal BP "dipping". Nocturnal hypertension and nondipping are particularly prevalent in individuals with autonomic neuropathies, sleep disorders (e.g., obstructive sleep apnoea), kidney disease, and metabolic or endocrine disorders, and are linked to hypertension mediated organ damage and cardiovascular risk. Therapeutic strategies targeting nocturnal BP remain debated. Chronotherapy (evening dosing of antihypertensives) has shown inconsistent results in clinical trials. Renal denervation and treatment of sleep-related breathing disorders may lower nocturnal BP and improve sleep quality. More research is needed to further clarify pathophysiology, measurement, therapeutic interventions, and overall management of nocturnal hypertension, issues on which this ESH position paper offers an in-depth review.

Nighttime blood pressure assessed by home monitors (HBP) appears to be a feasible and reliable alternative to ambulatory blood pressure (ABP) monitoring in adults. This study evaluated the optimal schedule for nighttime HBP monitoring in children and adolescents in terms of its agreement with nighttime ABP and association with preclinical target organ damage (TOD). Individuals aged 6-18 years referred for elevated blood pressure were evaluated with ABP (24 h) and HBP monitoring (daytime: 7 days, duplicate morning and evening measurements; night-time: 3 nights, 3 automated asleep measurements at 1-hour interval/night), as well as with determination of left ventricular mass index (LVMI), carotid intima-media thickness (cIMT) and carotid-femoral pulse wave velocity (PWV). Forty-nine children with all 9 nighttime HBP measurements (3 nights) were analyzed [mean age 13.4 ± 2.7 (SD) years, males 51%]. By averaging an increasing number of nighttime systolic HBP readings, there was a consistent trend towards stronger association with nighttime ABP (correlation coefficients r increased from 0.65 to 0.81), and with TOD indices (for LVMI r increased from 0.21 to 0.30; cIMT from 0.38 to 0.57; PWV from 0.60 to 0.69). However, no further improvement in these associations was observed by averaging more than 4 nighttime readings. The diagnostic agreement between the 2 methods in detecting nocturnal hypertension was progressively improved by averaging more nighttime HBP readings, and reached a plateau at 4 measurements. Four nighttime home BP measurements, performed during at least 2 nights appear to be the minimum requirement for a reliable assessment of nighttime HBP in children and adolescents, regarding its agreement with ABP and association with TOD. HBP monitoring in children and adolescents constitutes an alluring alternative to ABP monitoring concerning nighttime BP measurements since it provides reasonable agreement with ABP measurements and similar association with target organ damage indices. The optimal nighttime HBP schedule requires at least 4 nighttime home BP measurements, performed during at least 2 nights, which is in line with similar studies in adults.

Cuffless blood pressure (BP) measurement offers considerable potential for clinical practice but is a challenging technological field. Many are investigating pulse wave analysis with or without pulse arrival time in which machine learning is applied to pulsatile waveforms obtained with mobile devices (eg, wristbands, smartphones) to estimate BP. These methods generally require individual user calibration with cuff BP measurements or demographics (eg, age, sex). This calibration makes it difficult to evaluate the method's accuracy, and many studies claiming accuracy used inadequate testing procedures. Yet, publications and regulatory-cleared devices continue to rise, seemingly implying technological advancements. An update is provided on the flurry of activity in cuffless BP technologies over the last 2 to 3 years, covering the clinical need, the latest devices, recent publications based on pulse wave analysis and pulse arrival time, progress in developing validation standards for cuffless BP devices, and recent publications on other cuffless BP measurement principles. Despite the high volume of research and development, to date, there is no compelling evidence that pulse wave analysis and pulse arrival time can provide significant added value in BP measurement accuracy beyond the cuff BP or demographic data for calibration. Thus, it is reasonable to at least be skeptical of published and future studies on pulse wave analysis and pulse arrival time for cuffless BP measurement with uncertain testing procedures. It is important to focus on establishing robust validation standards for cuffless BP devices requiring individual user calibration and also pursuing cuffless and calibration-free BP measurement methodologies going forward.

Cardiovascular disease remains the leading cause of morbidity and mortality worldwide, underscoring the importance of effective primary prevention strategies. Current total cardiovascular disease (CVD) risk assessment tools, such as the Systematic Coronary Risk Evaluation 2 (SCORE2) in Europe and the Pooled cohort equations (PCEs) and Predicting Risk of CVD EVENTs (PREVENT) in the USA, aim to identify individuals at high CVD risk and guide clinical decision-making in the primary prevention setting. Statin therapy reduces cardiovascular events and is recommended as the first step for individuals with estimated CVD risk above specific thresholds. Moreover, the presence of risk modifiers, as well as the detection of asymptomatic atherosclerosis, reclassifies low-moderate CVD risk individuals into higher risk categories, contributing to tailored therapeutic decisions in primary prevention. However, differences in the performance of the available CVD risk assessment tools, the recommended thresholds for intervention, and the treatment targets by scientific societies introduce considerable inconsistency to the statin therapy practices. In addition, physicians' inertia and poor patients' adherence contribute to inadequate dyslipidemia control rates. This narrative review examines the available evidence on the current most used CVD risk assessment tools and the respective lipid-lowering recommendations, and highlights the role of targeted screening for asymptomatic atherosclerosis in terms of individualized therapy for primary prevention.

Hypertension is the leading modifiable risk factor for atrial fibrillation (AF) and is estimated to be present in >70% of AF patients. This Frontiers Review was prepared by 29 expert members of the AF-SCREEN International Collaboration to summarize existing evidence and knowledge gaps on links between hypertension, AF, and their cardiovascular sequelae; simultaneous screening for hypertension and AF; and the prevention of AF through antihypertensive therapy. Hypertension and AF are inextricably connected. Both are easily diagnosed, often silent, and frequently treated inadequately. Together, they additively increase the risk of ischemic stroke, heart failure, and many types of dementia, resulting in greater all-cause mortality, considerable disease burden, and increased health care expenditures. Automated upper arm cuff blood pressure devices with implemented technology can be used to simultaneously detect both hypertension and AF. However, positive screening for AF with an oscillometric blood pressure monitor still requires ECG confirmation. The current evidence suggests that high-risk individuals aged ≥65 years or with treatment-resistant hypertension could benefit from AF screening. Since antihypertensive therapy effectively lowers AF risk, particularly in individuals with left ventricular dysfunction, hypertension should be the key target for AF prediction and prevention rather than merely a comorbidity of AF. Nevertheless, several important gaps in knowledge need to be filled over the next years, including the ideal method and selection of patients for simultaneous screening of hypertension and AF and the optimal antihypertensive drug class and blood pressure targets for AF prevention.

The optimal method for the diagnosis of hypertension among patients on hemodialysis remains a controversial issue. Using 44-h ambulatory blood pressure (BP) monitoring (ABPM) as the reference-standard, we assessed the diagnostic performance of home BP monitoring (HBPM) versus routine dialysis-unit BP recordings in hemodialysis patients. Over a period of 2 weeks, the following methods were used for the assessment of hypertension: (i) routine predialysis and postdialysis BP recordings averaged over 6 consecutive dialysis sessions; (ii) HBPM for 7 days (duplicate morning and evening measurements, Microlife WatchBP Home N); (iii) 44-h ABPM (20-min intervals over an entire interdialytic interval, Microlife WatchBPO3). The study included 70 patients (mean age: 65.3 ± 13.2 years; treated hypertensives: 87.1%; 44-h ambulatory systolic/diastolic BP: 120.6 ± 15.2/66.3 ± 10.1 mmHg). Mean (standard deviation) of the differences between ambulatory daytime systolic BP (SBP) and routine predialysis SBP was -11.4 (13.4) mmHg, routine postdialysis SBP -4.0 (15.1) mmHg and home SBP -8.6 (10.7) mmHg. The area under the receiver-operating-characteristic-curve (AUC) for the detection of an ambulatory daytime SBP ≥ 135 mmHg was higher for home SBP [AUC: 0.934; 95% confidence interval (CI): 0.871-0.996] relative to predialysis SBP (AUC: 0.778; 95% CI: 0.643-0.913) and postdialysis SBP (AUC: 0.766; 95% CI: 0.623-0.909) (P = 0.02 for both comparisons). Home SBP at the cut-off point of 141.0 mmHg provided the best combination of sensitivity (85.7%) and specificity (92.9%) in diagnosing hypertension. In conclusion, the present study shows that among hemodialysis patients, HBPM for 1 week is superior to 2-week averaged routine predialysis or postdialysis BP in predicting ambulatory hypertension.

Hypertension presents the largest modifiable public health challenge due to its high prevalence, its intimate relationship to cardiovascular diseases, and its complex pathogenesis and pathophysiology. Low awareness of blood pressure elevation and suboptimal hypertension diagnosis serve as the major hurdles in effective hypertension management. Advances in artificial intelligence in hypertension have permitted the integrative analysis of large data sets including omics, clinical (with novel sensor and wearable technologies), health-related, social, behavioral, and environmental sources, and hold transformative potential in achieving large-scale, data-driven approaches toward personalized diagnosis, treatment, and long-term management. However, although the emerging artificial intelligence science may advance the concept of precision hypertension in discovery, drug targeting and development, patient care, and management, its clinical adoption at scale today is lacking. Recognizing that clinical implementation of artificial intelligence-based solutions need evidence generation, this opinion statement examines a clinician-centric perspective of the state-of-art in using artificial intelligence in the management of hypertension and puts forward recommendations toward equitable precision hypertension care.