The lack of outcome-driven operational thresholds limits the clinical application of home blood pressure (BP) measurement. Our objective was to determine an outcome-driven reference frame for home BP measurement. We measured home and clinic BP in 6470 participants (mean age, 59.3 years; 56.9% women; 22.4% on antihypertensive treatment) recruited in Ohasama, Japan (n=2520); Montevideo, Uruguay (n=399); Tsurugaya, Japan (n=811); Didima, Greece (n=665); and nationwide in Finland (n=2075). In multivariable-adjusted analyses of individual subject data, we determined home BP thresholds, which yielded 10-year cardiovascular risks similar to those associated with stages 1 (120/80 mm Hg) and 2 (130/85 mm Hg) prehypertension, and stages 1 (140/90 mm Hg) and 2 (160/100 mm Hg) hypertension on clinic measurement. During 8.3 years of follow-up (median), 716 cardiovascular end points, 294 cardiovascular deaths, 393 strokes, and 336 cardiac events occurred in the whole cohort; in untreated participants these numbers were 414, 158, 225, and 194, respectively. In the whole cohort, outcome-driven systolic/diastolic thresholds for the home BP corresponding with stages 1 and 2 prehypertension and stages 1 and 2 hypertension were 121.4/77.7, 127.4/79.9, 133.4/82.2, and 145.4/86.8 mm Hg; in 5018 untreated participants, these thresholds were 118.5/76.9, 125.2/79.7, 131.9/82.4, and 145.3/87.9 mm Hg, respectively. Rounded thresholds for stages 1 and 2 prehypertension and stages 1 and 2 hypertension amounted to 120/75, 125/80, 130/85, and 145/90 mm Hg, respectively. Population-based outcome-driven thresholds for home BP are slightly lower than those currently proposed in hypertension guidelines. Our current findings could inform guidelines and help clinicians in diagnosing and managing patients.

The objective of this study is to construct an International Database of HOme blood pressure in relation to Cardiovascular Outcome (IDHOCO). The main goal of this database is to determine outcome-based diagnostic thresholds for the self-measured home blood pressure (BP). Secondary objectives include investigating the predictive value of white-coat and masked hypertension, morning and evening BP, BP and heart rate variability, and the home arterial stiffness index. We also aim to determine an optimal schedule for home BP measurements that provides the most accurate risk stratification. Eligible studies are population-based, have fatal as well as nonfatal outcomes available for analysis, comply with ethical standards, and have been previously published in peer-reviewed journals. In a meta-analysis based on individual subject data, composite and cause-specific cardiovascular events will be related to various indexes derived by home BP measurement. The analyses will be stratified by a cohort and adjusted for the clinic BP and established cardiovascular risk factors. The database includes 6753 subjects from five cohorts recruited in Ohasama, Japan (n=2777); Finland (n=2075); Tsurugaya, Japan (n=836); Didima, Greece (n=665); and Montevideo, Uruguay (n=400). In these five cohorts, during a total of 62 106 person-years of follow-up (mean 9.2 years), 852 subjects died and 740 participants experienced a fatal or nonfatal cardiovascular event. IDHOCO provides a unique opportunity to investigate several hypotheses that could not reliably be studied in individual studies. The results of these analyses should be of help to clinicians involved in the management of patients with suspected or established hypertension.

Measurement of the ankle-brachial index (ABI) using a Doppler device is widely used to identify subjects with peripheral artery disease (PAD), and those who are at high risk of cardiovascular disease. This paper presents a systematic review (Medline/PubMed, Embase and Cochrane) and meta-analysis of studies assessing the usefulness of automated oscillometric devices for ABI estimation and PAD detection compared with the conventional Doppler method. A total of 25 studies including 4186 subjects were analyzed. A random-effects model analysis showed that the average oscillometric ABI was similar to the Doppler ABI (mean difference ± s.e. 0.020 ± 0.018, P=0.3) but that the absolute differences were significant (0.048 ± 0.009, P<0.01). The pooled correlation coefficient (r) between the oscillometric and Doppler ABI was 0.71 ± 0.05. Simultaneous arm-leg measurements resulted in a smaller difference between the average oscillometric ABI value and the average Doppler ABI value than did sequential measurements (-0.012 ± 0.022 vs. 0.040 ± 0.026, respectively, P<0.01). The average sensitivity and specificity of the oscillometric ABI estimation in PAD diagnosis was 69 ± 6% and 96 ± 1%, respectively (with Doppler ABI taken as the reference). These data suggest that an automated ABI measurement obtained by oscillometric blood pressure monitors is a reliable and practical alternative to the conventional Doppler measurement for the detection of PAD. To increase the sensitivity of the PAD diagnosis based on an oscillometric ABI, a higher threshold of 1.0 might be preferable.

Several studies with relatively small size and different design and end points have investigated the diagnostic ability of home blood pressure (HBP). This study investigated the usefulness of HBP compared with ambulatory monitoring (ABP) in diagnosing sustained hypertension, white coat phenomenon (WCP) and masked hypertension (MH) in a large sample of untreated and treated subjects using a blood pressure (BP) measurement protocol according to the current guidelines. A total of 613 subjects attending a hypertension clinic (mean age 53±12.4 (s.d.) years, men 57%, untreated 59%) had measurements of clinic BP (three visits, triplicate measurements per visit), HBP (6 days, duplicate morning and evening measurements) and awake ABP (20-min intervals) within 6 weeks. Sustained hypertension was diagnosed in 50% of the participants by ABP and HBP (agreement 89%, κ=0.79), WCP in 14 and 15%, respectively (agreement 89%, κ=0.56) and MH in 16% and 15% (agreement 88%, κ=0.52). Only 4% of the subjects (27/613) showed clinically significant diagnostic disagreement with BP deviation >5 mm Hg above the diagnostic threshold (for HBP or ABP). By taking ABP as reference, the sensitivity, specificity, positive and negative predictive value of HBP in detecting sustained hypertension were 90, 89, 89 and 90%, respectively, WCP 61, 94, 64 and 94% and MH 60, 93, 60 and 93%. Similar diagnostic agreement was found in untreated and treated subjects. HBP appears to be a reliable alternative to ABP in the diagnosis of hypertension and the detection of WCP and MH in both untreated and treated subjects.

For more than half a century measurement of blood pressure in the doctor's office using a mercury sphygmomanometer and the auscultatory method has been the cornerstone for hypertension management. However, due to the environmental and service issues mercury devices will not be available in the near future. As the mercury sphygmomanometer is being progressively eliminated from clinical use, it is being replaced by a variety of devices, which may not have been validated. This change in the practice of measurement may have an unpredictable impact on the threshold levels used for the diagnosis of hypertension and may also influence the management of hypertension. This expert document provides (i) information on the current availability of technologies and devices with potential for professional use (oscillometric, hybrid, aneroid and mercury devices) and the advantages and limitations of each one of them, and (ii) guidance on the requirements and selection of mercury-free blood pressure monitors for professional use. With the increasing use of automated oscillometric devices it is likely that the auscultatory technique will soon become redundant. However, consideration will be given to some of the technical aspects of the oscillometric technique and to the educational aspects of auscultation that may make it premature to abandon the technique altogether.

Ambulatory blood pressure (ABP) monitoring is recommended as a standard method for the evaluation of resistant hypertension (RH). This study assessed the diagnostic value of home blood pressure (HBP) monitoring in RH. Subjects on stable treatment with ≥3 antihypertensive drugs were included. Clinic RH (CRH) was defined as elevated clinic blood pressure and true RH (TRH) as elevated ABP. The diagnosis of CRH was verified by ABP and HBP monitoring. The diagnostic value of HBP was assessed by taking ABP as reference method. Threshold for hypertension diagnosis was ≥135/85 mm Hg (systolic and/or diastolic) for HBP and awake ABP and ≥140/90 mm Hg for clinic blood pressure. Among 73 subjects on ≥3 antihypertensive drugs, 44 (60%) had CRH and 40 (55%) TRH. There was agreement between ABP and HBP in diagnosing CRH in 82% of the cases (26 subjects (59%) with CRH and 10 (23%) without CRH; kappa 0.59). Regarding the diagnosis of TRH, there was agreement between ABP and HBP in 74% of the cases (36 subjects (49%) with TRH and 18 (25%) without TRH; kappa 0.46). The sensitivity, specificity, and positive and negative predictive values of HBP in detecting CRH were 93%, 63%, and 81% and 83%, respectively, and TRH were 90%, 55%, and 71%, and 82%, respectively (ABP taken as reference method). These data suggest that HBP is a reliable alternative to ABP in the evaluation of RH. These methods are necessary in both uncontrolled and controlled subjects on triple therapy to detect the white coat phenomenon and also masked RH.

This study validated a hybrid mercury-free device as a replacement of the mercury sphygmomanometer for professional use, and also as a standard for future validations. A validation study was performed according to the European Society of Hypertension International Protocol 2010 (ESH-IP) in 33 subjects using simultaneous blood pressure (BP) measurements. A total of six BP measurements were taken per participant simultaneously by a supervisor (S; hybrid auscultatory device Nissei DM3000) and two observers (A and B; mercury sphygmomanometers). ESH-IP analysis (99 BP readings): mean device-observer systolic/diastolic BP difference 0.2±2.0/0.1±2.0 mm Hg; systolic BP differences ≤5/10/15 mm Hg in 97/99/99 readings, respectively (diastolic 98/99/99). All 33 subjects had 2 of 3 BP differences ≤5 mm Hg and none without a difference ≤5 mm Hg. Further analysis (198 BP readings): mean differences S-A 0.1±2.4/0.2±2.4 mm Hg (systolic/diastolic), S-B 0.3±2.1/0.2±2.2, A-B 0.2±2.4/0.0±2.3; differences ≤2 mm Hg S-A in 88/84% (systolic/diastolic), S-B 87/85%, A-B 87/86% and ≤4 mm Hg S-A 95/96%, S-B 95/96%, A-B 95/98%. In conclusion, a hybrid mercury-free auscultatory BP monitor comfortably passed the ESH-IP 2010 requirements and has the same level of accuracy as the mercury sphygmomanometer. This device appears to be a reliable alternative to the mercury sphygmomanometer for professional use and also as a standard for future validations.