Pulse Wave Calibration and Implications for Blood Pressure Measurement: Systematic Review and Meta-Analysis

Central aortic systolic pressure (CASP) can be estimated via filtering of the peripheral pulse wave (PPW) following calibration to brachial blood pressure. Recent studies suggest PPW calibration to mean arterial pressure (MAP) and diastolic BP (DBP) provides more accurate CASP estimates (CASPMD) versus conventional calibration to systolic BP (SBP) and DBP (CASPSD). However, the peak of the MAP-DBP calibrated PPW, that is, SBPMD, is rarely reported or used for BP amplification calculations, despite CASPMD being derived from it. We aimed to calculate the unreported SBPMD from studies using MAP-DBP calibration for estimation of CASPMD and compared it with oscillometric brachial SBP (brSBP). Medline database was searched to March 18, 2020. Meta-analysis includes studies reporting noninvasive CASPSD, CASPMD, brSBP, and brachial DBP. SBPMD was calculated using linear function equations. Data from 21 studies used 8 different BP monitors (13 460 participants, mean age: 54±10 years, 57% female, brachial blood pressure: 130±14/79±9 mm Hg). Weighted mean difference between SBPMD and brSBP was 10 mm Hg (range, -2 to 17 mm Hg) and appeared device specific. Calibration of brachial versus radial PPWs to brachial blood pressure showed a greater disparity between SBPMD and brSBP (14 versus 2 mm Hg). BP amplification was similar comparing SBP-DBP versus MAP-DBP calibrations (brSBP-CASPSD versus SBPMD-CASPMD: 9 versus 11 mm Hg), with no instances of reverse BP amplification. PPWs calibrated to MAP-DBP to derive CASPMD generates SBPMD that differs markedly from brSBP with some oscillometric BP monitors. These findings have important implications for BP monitor accuracy, BP amplification, PPW calibration recommendations, and studies of associations between CASP versus SBP and outcomes

Identifying and treating high blood pressure in men under 55 years with grade 1 hypertension: the TREAT CASP study and RCT

Background: There is uncertainty regarding whether or not younger (i.e. aged < 55 years), low-risk patients with grade 1 hypertension (i.e. a clinic blood pressure of 140–159/90–99 mmHg) should be treated with blood pressure-lowering medication. This is a heterogeneous group of patients because of variation in systolic/pulse pressure amplification from the central aorta to the brachial artery. It is hypothesised that within grade 1 hypertension, patients can be divided into those with high central aortic systolic pressure and those with low central aortic systolic pressure. Objectives: The aims of this study were to (1) evaluate whether or not non-invasive central aortic systolic pressure measurement can better identify younger patients with grade 1 hypertension, who are more likely to have an increased left ventricular mass index; and (2) determine whether or not blood pressure lowering regresses early cardiac structural change in patients with high central aortic systolic pressure. Setting: A university hospital with satellite primary care recruitment sites. Participants: A total of 726 men (aged 18 to < 55 years) were screened to identify 162 men with grade 1 hypertension and low or high central aortic systolic pressure. Blood pressure status was classified according to seated clinic blood pressure, central aortic systolic pressure and 24-hour ambulatory blood pressure. Design: (1) Evaluating the strength of the correlation between central aortic systolic pressure, clinic blood pressure and 24-hour ambulatory blood pressure with left ventricular mass index in 162 patients; (2) a 12-month randomised controlled trial in patients with grade 1 hypertension and high central aortic systolic pressure (i.e. a central aortic systolic pressure of ≥ 125 mmHg) (n = 105), using a prospective, open, blinded, end-point design; and (3) a 12-month observational study in 57 patients with grade 1 hypertension and low central aortic systolic pressure (i.e. a central aortic systolic pressure of < 125 mmHg). Interventions: Randomised controlled trial – patients with high central aortic systolic pressure randomised to blood pressure lowering medication (50–100 mg of losartan ± 5–10 mg of amlodipine once daily) versus usual care (no treatment) for 12 months. Main outcomes: Randomised controlled trial primary end point – change in left ventricular mass index as measured by cardiac magnetic resonance imaging, comparing treatment with no treatment. Results: (1) At baseline, left ventricular mass index was higher in men with high central aortic systolic pressure than in those with low central aortic systolic pressure (mean ± standard deviation 67.9 ± 8.8 g/m2 vs. 64.0 ± 8.5 g/m2; difference 4.0 g/m2, 95% confidence interval 1.1 to 6.9 g/m2; p < 0.01). Central aortic systolic pressure was not superior to clinic blood pressure as a determinant of left ventricular mass index. Univariate analysis, regression coefficients and slopes for left ventricular mass index were similar for clinic systolic blood pressure, ambulatory systolic blood pressure and central aortic systolic pressure. (2) In the randomised controlled trial, blood pressure-lowering treatment reduced central aortic systolic pressure (–21.1 mmHg, 95% confidence interval – 24.4 to –17.9 mmHg; p < 0.001) and clinic systolic blood pressure (–20.0  mmHg, 95% confidence interval – 23.3 to –16.6 mmHg; p < 0.001) versus no treatment. Treatment was well tolerated and associated with a greater change (i.e. from baseline to study closeout) in left ventricular mass index versus no treatment [–3.3 g/m2 (95% confidence interval –4.5 to –2.2 g/m2) vs. –0.9 g/m2 (95% confidence interval –1.7 to –0.2 g/m2); p < 0.01], with a medium-to-large effect size (Cohen’s d statistic –0.74). (3) Patients with low central aortic systolic pressure had no significant change in left ventricular mass index after 12 months (mean change –0.5 g/m2, 95% confidence interval –1.2 to 0.2 g/m2; p = 0.18). Conclusions: Men with grade 1 hypertension and high central aortic systolic pressure tended to have higher clinic blood pressure and more hypertension-mediated cardiac structural change than those with low central aortic systolic pressure. Central aortic systolic pressure was not superior to clinic blood pressure or ambulatory blood pressure at stratifying risk of increased left ventricular mass index. Blood pressure-lowering treatment led to a regression of left ventricular mass index in men with grade 1 hypertension and high central aortic systolic pressure compared with no treatment. Limitations: The study was limited to a moderate sample of men and there was a low prevalence of very high amplification

Effects of treatment withdrawal on brachial and central aortic pressure after direct renin inhibition or angiotensin receptor blockade

Whilst sustained lowering of brachial systolic blood pressure (Br-SBP) and central aortic systolic pressure (CASP) have been demonstrated in patients with hypertension, effects of treatment withdrawal on these parameters have not been investigated. The ASSERTIVE study previously reported more sustained control of Br-SBP with aliskiren versus telmisartan in patients with hypertension, following 7-days treatment withdrawal. In this ASSERTIVE sub-study, we hypothesised that aliskiren would similarly exert more sustained control of CASP than telmisartan during treatment withdrawal

Application of non-invasive central aortic pressure assessment in clinical trials: Clinical experience and value

Pressure measured with a cuff and sphygmomanometer in the brachial artery is accepted as an important predictor of future cardiovascular (CV) events. However, recent clinical evidence suggests that central aortic pressure (CAP) provides additional information for assessing CV risk than brachial blood pressure (BrBP). Central hemodynamics can now be non-invasively assessed with a number of devices, however, the methodology employed to measure CAP, in order to better identify the patients at higher CV risk in clinical practice, is still controversial. The purpose of this article is to review the technology behind the non-invasive measurement of CAP via the effects of different classes of antihypertensive drugs on CAP and the data supporting the predictive value of assessing CAP on clinical outcomes, and to foster the transfer of methodological knowledge from clinical trials into routine clinical practice

Measurement of blood pressure in the leg - a statement on behalf of the British and Irish Hypertension Society

This is the final version. Available on open access from Springer Nature via the DOI in this recordAnkle blood pressure (BP) measurement is necessary for the diagnosis of hypertension where measurements are not possible due to medical conditions or limb deformities. Based on a recent review of the evidence, we recommend an ankle BP threshold of ≥155/90 mmHg to define high blood pressure in patients who do not have vascular disease. We recommend that ankle BP readings are taken with the subject lying down, using a validated automated device with the cuff placed around the ankle/lower calf.Wellcome TrustRoyal SocietyNational Institute for Health Research (NIHR

Effects of exercise on central aortic pressure before and after treatment with renin-angiotensin system blockade in patients with hypertension.

Brachial blood pressure increases with exercise and an excessive rise predicts increased cardiovascular risk. Measurement of brachial blood pressure alone may exaggerate the true blood pressure elevation due to exercise-induced change to pressure amplification. Whether blood pressure-lowering treatment modulates pressure amplification during exercise is unknown

National survey of feasibility of NIV trials for management of children with bronchiolitis.

Background: Bronchiolitis is a major cause of admission to hospital in children. Non-invasive ventilation (NIV) support with continuous positive airway pressure (CPAP) or high-flow nasal cannula (HFNC) oxygen is routinely used for infants in the UK with bronchiolitis. Objective: To establish UK paediatric practice regarding management of bronchiolitis, and to explore issues pertinent to the design of a potential future randomised controlled trial of NIV. Design: Screening logs were completed in hospitals in England capturing information on paediatric bronchiolitis admissions. An online national survey of clinical practice was disseminated to healthcare professionals (HCPs) across the UK to ascertain current management strategies. Results: Screening logs captured data on 393 infants from 8 hospitals. Reasons for admission were most commonly respiratory distress and/or poor fluid intake. Oxygen was administered for 54% of admissions. Respiratory (CPAP and HFNC) and non-respiratory support administered varied considerably. The national survey was completed by 111 HCPs from 76 hospitals. Data were obtained on criteria used to commence and wean NIV, responsibilities for altering NIV settings, minimum training requirements for staff managing a child on NIV, and numbers of trained staff. Most centres were interested in and capable of running a trial of NIV, even out of normal office hours. Conclusions: Respiratory and non-respiratory management of bronchiolitis in UK centres varies widely. A trial of HFNC oxygen therapy in this group of patients is feasible and HCPs would be willing to randomise patients into such a trial. Future work should focus on defining trial eligibility criteria

Non-invasive ventilation for the management of children with bronchiolitis (NOVEMBR): a feasibility study and core outcome set development protocol

Background: Bronchiolitis is an acute lower respiratory infection which predominantly affects young children. Treatment for bronchiolitis is limited to supportive therapy. Nasal oxygen therapy is part of routine care, and delivery now incorporates varying levels of non-invasive continuous positive airway pressure and/or high-flow nasal cannula oxygen therapy. Despite wide clinical use, there remains a lack of evidence on the comparative effectiveness and safety of these interventions. Furthermore, research in this field is hampered by the use of multiple outcome measures in current clinical trials. Methods/design: This mixed methods study includes a systematic review of outcome measures, telephone interviews with parents, focus group workshops and a Delphi survey with healthcare professionals and parents. These methods will be used to identify and prioritise outcomes for inclusion in a core outcome set and to explore issues pertinent to the design of a future randomised controlled trial comparing different modes of oxygen therapy for bronchiolitis. UK hospitals will also be contacted and asked to complete a survey to provide an overview of current practice to enable assessment of capability and capacity to run a future clinical trial. Discussion: This study will facilitate the design of a future clinical trial of non-invasive ventilation in children with bronchiolitis which is acceptable to important stakeholders. Furthermore, core outcome set development will improve standardisation, measurement and reporting of clinically important outcomes in bronchiolitis. Trial registration: ISRCTN Registry, ISRCTN75766048. Registered on 18 December 2017. This study was retrospectively registered in the ISRCTN Registry and on the Core Outcome Measures in Effectiveness Trials (COMET) Initiative database (15 September 2017)

Which outcomes should be used in future bronchiolitis trials? Developing a bronchiolitis core outcome set using a systematic review, Delphi survey and a consensus workshop

Objectives The objective of this study was to develop a core outcome set (COS) for use in future clinical trials in bronchiolitis. We wanted to find out which outcomes are important to healthcare professionals (HCPs) and to parents and which outcomes should be prioritised for use in future clinical trials. Design and setting The study used a systematic review, workshops and interviews, a Delphi survey and a final consensus workshop. Results Thirteen parents and 45 HCPs took part in 5 workshops; 15 other parents were also separately interviewed. Fifty-six items were identified from the systematic review, workshops and interviews. Rounds one and two of the Delphi survey involved 299 and 194 participants, respectively. Sixteen outcomes met the criteria for inclusion within the COS. The consensus meeting was attended by 10 participants, with representation from all three stakeholder groups. Nine outcomes were added, totalling 25 outcomes to be included in the COS. Conclusion We have developed the first parent and HCP consensus on a COS for bronchiolitis in a hospital setting. The use of this COS will ensure outcomes in future bronchiolitis trials are important and relevant, and will enable the trial results to be compared and combined

Identifying Isolated Systolic Hypertension From Upper-Arm Cuff Blood Pressure Compared With Invasive Measurements

Isolated systolic hypertension (ISH) is the most common form of hypertension and is highly prevalent in older people. We recently showed differences between upper-arm cuff and invasive blood pressure (BP) become greater with increasing age, which could influence correct identification of ISH. This study sought to determine the difference between identification of ISH by cuff BP compared with invasive BP. Cuff BP and invasive aortic BP were measured in 1695 subjects (median 64 years, interquartile range [55-72], 68% male) from the INSPECT (Invasive Blood Pressure Consortium) database. Data were recorded during coronary angiography among 29 studies, using 21 different cuff BP devices. ISH was defined as ≥130/<80 mm Hg using cuff BP compared with invasive aortic BP as the reference. The prevalence of ISH was 24% (n=407) according to cuff BP but 38% (n=642) according to invasive aortic BP. There was fair agreement (Cohen κ, 0.36) and 72% concordance between cuff and invasive aortic BP for identifying ISH. Among the 28% of subjects (n=471) with misclassification of ISH status by cuff BP, 20% (n=96) of the difference was due to lower cuff systolic BP compared with invasive aortic systolic BP (mean, -16.4 mm Hg [95% CI, -18.7 to -14.1]), whereas 49% (n=231) was from higher cuff diastolic BP compared with invasive aortic diastolic BP (+14.2 mm Hg [95% CI, 11.5-16.9]). In conclusion, compared with invasive BP, cuff BP fails to identify ISH in a sizeable portion of older people and demonstrates the need to improve cuff BP measurements