Blood Pressure Monitoring

Validation of the single-cuff oscillometric blood pressure monitor InBody BPBIO750 for public spaces according to the Association for the Advancement of Medical Instrumentation/European Society of Hypertension/International Organization for Standardization Universal Standard Objective The aim of this study was to evaluate the accuracy of the single upper-arm cuff oscillometric blood pressure (BP) monitor InBody BPBIO750 developed for self-measurement by adults in public spaces (kiosk) according to the Association for the Advancement of Medical Instrumentation/European Society of Hypertension/International Organization for Standardization (AAMI/ESH/ISO) Universal Standard (ISO 81060-2:2018). Methods Subjects were recruited to fulfil the age, gender, BP and cuff distribution criteria of the AAMI/ESH/ISO Universal Standard in general population using the same arm sequential BP measurement method. Results A total of 102 subjects were recruited and 85 were analyzed [mean age 56.7 ± 15.4 (SD) years, 40 men, arm circumference 32.3 ± 5.3 cm, range 22–42 cm]. For validation criterion 1, the mean ± SD of the differences between the test device and reference BP readings was 2.2 ± 6.1/−2.2 ± 5.2 mmHg (systolic/diastolic). For criterion 2, the SD of the averaged BP differences between the test device and reference BP per subject was 5.00/4.63 mmHg (systolic/diastolic). Conclusion The InBody BPBIO750 device fulfilled all the requirements of the AAMI/ESH/ISO Universal Standard (ISO 81060-2:2018) in general population and can be recommended for clinical use in adults. Received 14 September 2020 Accepted 16 November 2020 Correspondence to George S. Stergiou, MD, FRCP, Hypertension Center STRIDE-7, National and Kapodistrian University of Athens, School of Medicine, Third Department of Medicine, Sotiria Hospital, 152 Mesogion Avenue, Athens 11527, Greece, Tel: +30 2107763117; fax: +30 2107719981; e-mail: gstergi@med.uoa.gr Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Association between inter-arm difference in SBP and central blood pressure in a Beijing community cohort Objective The inter-arm SBP difference (IASBPD) can serve as a predictor of cardiovascular disease (CVD). In this study, we aimed to determine the relationship between IASBPD and central blood pressure (CBP). Methods The study cohort comprised of 7842 eligible individuals. Their BPs were assessed simultaneously in both arms using an Omron BP-203RPEIII vascular profiler, and the IASBPD was measured as the absolute difference in these values (absolute value of left minus right). The CBP was noninvasively measured using an Omron HEM-9000AI device. Multivariate regression analysis was used to assess the association between the central SBP (cSBP) and the IASBPD. Results An IASBPD of ≥10 mmHg was positively associated with the cSBP (β = 2.26; 95% confidence interval, 1.04–3.48; P < 0.001). The interaction test showed no significant interactions between the IASBPD and any of the assessed covariates (age group; sex; BMI; smoking status; heart rate group; the presence of hypertension, diabetes, or CVD; and antihypertensive drug use) when the cSBP was used as the outcome in the subgroup analysis. Conclusion The mechanism underlying the ability of the IASBPD to predict CVD may partly involve an increase in the CBP. Received 8 February 2020 Accepted 9 November 2020 Correspondence to Yan Zhang, Division of Cardiology, Peking University First Hospital Dahongluochang Street, Xicheng District, Beijing, 100034, China, Tel: +86 136 2106 2738; fax: +86 10 6613 7748; e-mail: drzhy1108@163.com Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Relation between nocturnal decline in blood pressure and choroidal thickness: a comparative analysis in dipper vs. non-dipper hypertensive patients Purpose To compare choroidal thickness (ChT) and echocardiographical changes in patients with dipper and non-dipper systemic arterial hypertension (HT). Methods Patients with HT were evaluated in two groups according to the 24-hour ambulatory BP monitoring. Compared to day-time values, those whose night-time SBP decreased ≥10% were defined as dippers, and those whose SBP decreased <10% were defined as non-dippers. Transthoracic echocardiography was conducted in all patients. ChT and central macular thickness were measured with spectral-domain optical coherence tomography. ChT was obtained at the subfoveal, 1500 µm nasal and temporal to the fovea. Results Thirty non-dipper (18 females and 12 males) and 23 dipper (16 females and seven males) hypertensive patients were recruited. Sex distribution and the mean age were similar between the groups (P = 0.472; P = 0.12). Disease duration was longer in the non-dipper group (8 ± 3.39 vs. 4.96 ± 1.19 years, P = 0.001). The non-dipper group had lower ChT in subfoveal and temporal locations (P = 0.02 and 0.03, respectively) and higher left atrial volume index (LAVI) and pulmonary valve maximum flow (PV-max; P < 0.001). The night-time SBP was negatively correlated with ChT (P = 0.048) and positive correlated with LAVI and PV-max (P < 0.05). However those correlations were not significant when were controlled by the possible confounding factors as disease duration, age and gender. Conclusion Non-dipper HT patients may have thinner choroid than dippers due to longer duration of HT and higher ambulatory BP levels. Received 27 May 2020 Accepted 28 October 2020 Correspondence to Sedat Tas, MD, Department of Cardiology Manisa City Hospital, 45040 Manisa, Turkey, Tel: +905052919458; e-mail: sedattas2000@yahoo.com Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Could aortic arch calcification help in detection of hypertensive retinopathy? Objective Hypertension-induced end-organ damage is one of the important determinants of morbidity and mortality in patients with hypertension. All types of hypertension-induced end-organ damages start with vascular damage. Vascular calcification is a marker of vascular damage and aortic arch calcification (AAC) is one of the easily identifiable types of vascular calcification. We hypothesized that AAC predicts retinopathy in hypertensive patients. Methods Consecutive hypertensive patients without diabetes mellitus were included. Chest radiography in the posterior-anterior was used to assess the presence of AAC. All patients underwent ophthalmologic examination for retinopathy. Results We included 495 hypertensive patients in this study. Of these, 306 (62%) had hypertensive retinopathy. Patients with hypertensive retinopathy had significantly higher prevalence of AAC as compared to the patients without hypertensive retinopathy (88% vs. 22%, P < 0.001). We found a strong and positive correlation between hypertensive retinopathy and AAC grades (r = 639, P < 0.001). Receiver operator characteristics curve analysis yielded a strong predictive ability of AAC for the presence of hypertensive retinopathy [area under curve = 0.814, 95% confidence interval (CI): 0.775–0.853, P < 0.0001]. In multivariate logistic regression analysis, presence of AAC [odds ratio (OR) 13.128; CI: 7.894–21.832] and serum glucose levels (OR 1.020; CI: 1.003–1.037) were strongly and independently associated with hypertensive retinopathy. Conclusion Presence of AAC on chest radiograph is strongly and independently associated with retinopathy in nondiabetic hypertensive patients. This simple, inexpensive and widely available tool may help in early detection of retinopathy in patients with hypertension. Received 22 October 2019 Accepted 8 October 2020 Correspondence to Adem Adar, MD, Department of Cardiology, Karabuk University Faculty of Medicine, Karabuk, Turkey, Tel: +90 507 231 68 78; e-mail: aadar@karabuk.edu.tr Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Abnormal diurnal blood pressure profile and hypertension-mediated organ damage in nondiabetic chronic kidney disease G1-G3b patients Objective Chronic kidney disease (CKD) is associated with high cardiovascular risk. Prevalence of hypertension and hypertension-mediated organ damage (HMOD) increases with CKD progression. Nocturnal blood pressure (BP) is a strong predictor of cardiovascular complications. This cross-sectional study investigated the link between the diurnal BP profile and HMOD in nondiabetic CKD G1-G3b patients. Methods We investigated 109 CKD patients and 41 apparently healthy persons as controls. All subjects underwent 24-ambulatory blood pressure monitoring (ABPM), echocardiography with left ventricular mass index (LVMI) calculation and pulse wave velocity (PWV) measurement. Results Hypertension was present in 84% of CKD patients. SBP-24 and DBP-24, SBP-day and DBP-day did not differ between CKD and controls. Significant differences were found in SBP-night and DBP-night. The nondipping BP profile (SBP-night/SBP-day ratio ≥0.9) was found in 62% of CKD patients and 32% of controls (P < 0.005). Nocturnal hypertension was found in 56% of CKD patients. LVMI was higher in CKD compared to controls, higher in nondipping than dipping CKD patients, and higher in patients with nocturnal hypertension than without nocturnal hypertension. Abnormal left ventricular geometry was found in 72% nondipping and 43% dipping CKD patients. PWV was higher in CKD than in controls, in patients with nocturnal hypertension than without nocturnal hypertension but did not differ between CKD nondippers and dippers. Conclusion The nondipping BP profile and nocturnal hypertension are associated with HMOD in G1-G3b CKD patients. Hence, there is a need for more extensive use of ABPM for individual risk assessment and personalization of antihypertensive treatment in CKD patients. Received 5 May 2020 Accepted 22 September 2020 Correspondence to Paweł Stróżecki, MD, PhD, Department of Transplantology and Surgery, University Hospital No 1, Skłodowskiej-Curie 9, 85-094 Bydgoszcz, Poland, Tel: +48 525854386; fax: +48 525854450; e-mail: st_pawel@cm.umk.pl Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Association of vitamin D deficiency with arterial stiffness in newly diagnosed hypertension Objective Vitamin D has beneficial effects on vascular endothelial function, blood pressure (BP) and arterial stiffness. Arterial stiffness increases in early-stage hypertensive patients and it is a strong predictor of cardiovascular morbidity and mortality. The purpose of this study was to assess the association between serum 25-hydroxyvitamin D (25-OH D) levels and arterial stiffness in patients with newly diagnosed hypertension. Method Our study included 100 newly diagnosed hypertensive patients (63 male, 37 female and mean age: 51.7 ± 10.3 years) without cardiovascular disease, malignancy, chronic kidney disease and diabetes mellitus. Patients were divided into two groups: vitamin D deficiency group (<20 ng/ml) and normal vitamin D group (≥20 ng/ml). Twenty-four-hour, daytime and nighttime ambulatory BP readings were recorded. Mobil-O-Graph ARC solver algorithm was used to evaluate arterial stiffness parameters of pulse wave velocity (PWV) (m/s), augmentation index normalized with 75/min heart rate (Alx@75). Results Patients with vitamin D deficency had higher values of Alx@75 and PWV values (20.9 ± 9 vs. 16.8 ± 6.9, P = 0.018 and 8.37 ± 1.16 vs. 6.9 ± 0.9, P = 0.001, respectively) despite similar 24-hour ambulatory BP monitoring in both groups. Level of serum calcium was significantly higher in vitamin D deficiency group (9.5 ± 0.23 vs. 9.3 ± 0.12, P = 0.007). Nighttime SBP was higher in vitamin D deficiency group (133.2 ± 14.3 mmHg vs. 126.3 ± 17.2 mmHg; P = 0.03) and also, vitamin D deficiency group had non-dipping SBP pattern compared to normal Vitamin D group (P = 0.013). Conclusion Vitamin D deficiency is associated with increased arterial stiffness in newly diagnosed hypertensive patients in terms of increased PWV and Alx@75 values. Received 20 May 2020 Accepted 28 September 2020 Correspondence to Sinem Cakal, MD, Department of Cardiology, Haseki Training and Research Hospital, Uğur Mumcu, Belediye Sokak No:7, 34265 Sultangazi/İstanbul, Turkey, Tel: +(90) 505 755 17 70; fax: +(90) 212 453 20 00; e-mail: sinemdnz@gmail.com Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Evaluation of cuff deflation and inflation rates on a deep learning-based automatic blood pressure measurement method: a pilot evaluation study Objective The aim of this study was to evaluate the performance of using a deep learning-based method for measuring SBPs and DBPs and the effects of cuff inflation and deflation rates on the deep learning-based blood pressure (BP) measurement (in comparison with the manual auscultatory method). Methods Forty healthy subjects were recruited. SBP and DBP were measured under four conditions (i.e. standard deflation, fast deflation, slow inflation and fast inflation) using both our newly developed deep learning-based method and the reference manual auscultatory method. The BPs measured under each condition were compared between the two methods. The performance of using the deep learning-based method to measure BP changes was also evaluated. Results There were no significant BP differences between the two methods (P > 0.05), except for the DBPs measured during the slow and fast inflation conditions. By applying the deep learning-based method, SBPs measured from fast deflation, slow inflation and fast inflation decreased significantly by 3.0, 3.5 and 4.7 mmHg (all P < 0.05), respectively, in comparison with the standard deflation condition. Whereas, corresponding DBPs measured from the slow and fast inflation conditions increased significantly by 5.0 and 6.8 mmHg, respectively (both P < 0.05). There were no significant differences in BP changes measured by the two methods in most cases (all P > 0.05, except for DBP change in the slow and fast inflation conditions). Conclusion This study demonstrated that the deep learning-based method can achieve accurate BP measurement under the deflation and inflation conditions with different rates. Received 18 June 2020 Accepted 28 October 2020 Correspondence to Peiyu He, PhD, College of Electronics and Information Engineering, Sichuan University, Chengdu 610064, China, Tel: +8602885463873; e-mail: hpysbsy@163.com Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Hemodynamic response to heated water immersion in older individuals with hypertension The aim of this study was to evaluate blood pressure (BP), heart rate, arterial stiffness and endothelial reactivity responses to heated water immersion in older individuals with hypertension. Thirty-five sedentary individuals (67 ± 5 years) under treatment for hypertension were randomly assigned to water-based [n = 20; 30 min of seated resting in a heated swimming pool (30–32 ºC)] or land-based group [n = 15; 30 min of seated resting in a quiet room with controlled temperature (21–23 ºC)]. BP, heart rate, arterial stiffness and endothelial reactivity were measured before, immediately after (post) and 45 min after (recovery) each session. Heart rate reduced (P < 0.05) during the land-based session, and the reduction was maintained at post (~7 bpm) and recovery (~9 bpm), but no heart rate changes occurred during and after the water-based session. Systolic/diastolic BP increased (P = <0.001) at post (~29/10 mmHg) and recovery (~10/7 mmHg) in the water-based group, but not in the land-based group. No significant changes in pulse wave velocity and endothelial reactivity occurred in both groups. These results suggest that the hemodynamic response to heated water immersion should be taken into account when assessing the effect of heated water-based exercise on postexercise hypotension in older individuals with hypertension. Received 24 June 2020 Accepted 13 October 2020 Correspondence to Emmanuel Gomes Ciolac, PhD, Faculdade de Ciências, Departamento de Educação Física, Laboratório de Pesquisas em Exercício Físico e Doenças Crônicas, Universidade Estadual Paulista – UNESP, Avenue Engenheiro Luiz Edmundo Carrijo Coube 14-06, Bauru, Brazil,17033-360, Tel: +55 14 3103 9437; fax: +55 14 3103 6082; e-mail: emmanuel.ciolac@unesp.br/Twitter: @ProfessorCiolac Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Validation of the blood pressure measurement technology used in the Novacor Diasys 3 (DIS-0001-00) upper arm device for ambulatory blood pressure measurement, according to the requirements of the AAMI/ANSI/ISO 81060-2: 2013 standard (for both a general study and a cardiac-stress study in adults) and of the European Society of Hypertension International Protocol revision 2010 Objective The objective of this study was to determine the accuracy of the oscillometric blood pressure measurement technology of the Novacor Diasys 3 (model number DIS-0001-00) blood pressure monitor, intended for ambulatory blood pressure measurement, when used with the recommended Standard (ACC-0213-00), Large (ACC-0214-00) and Paediatric (ACC-0215-00) cuffs. Methods The Novacor Diasys 3 (model number DIS-0001-00) was evaluated according to the requirements of the AAMI/ANSI/ISO 81060-2:2013 standard, including an additional cardiac-stress study, a requirement for ambulatory blood pressure measurement devices. It was also validated according to the requirements of the European Society of Hypertension International Protocol revision 2010. The protocol requirements for all thee studies were followed precisely. Results The Novacor Diasys 3 (model number DIS-0001-00) fulfilled all of the requirements for a pass in each of the three studies. In the primary AAMI/ANSI/ISO 81060-2:2013 study, the Criterion 1 errors were +3.9 mmHg ± 2.9 mmHg for SBP and +3.4 ± 2.5 mmHg for DBP. Conclusion The Novacor Diasys 3 (model number DIS-0001-00), when used with the recommended cuffs, can be recommended for ambulatory blood pressure measurement in the adult population. Received 22 June 20209September2020 Accepted 17 September 2020 Correspondence to Neil Atkins, Medaval Ltd., Unit 107, SBC, Serpentine Ave., Ballsbridge, Dublin D04 H522, Ireland, Tel: +353 1 664 3768; e-mail: neil.atkins@medaval.ie Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Prevalence of aberrant blood pressure readings across two automated intraoperative blood pressure monitoring systems among patients undergoing caesarean delivery Objectives Aberrant automated blood pressure (BP) readings during caesarean delivery may lead to disruptions in monitoring. The present study compared the frequency of aberrant BP readings across two types of commercially available BP monitoring systems in use during caesarean delivery. Methods This was a retrospective observational study using two comparable patient cohorts that resulted from simultaneous introduction of two types of monitors into a single obstetric surgical center in which similar patients were treated for the same surgical procedure by the same set of clinicians during the same year. Our primary hypothesis was that aberrant readings were significantly associated with the type of monitor being used for BP measurement, controlling for a variety of relevant covariates as specified in the analytic plan Results A total of 1418 cesarean delivery patients met inclusion criteria. Gaps of at least 6 min in machine-captured BP readings occurred in 159 (21.1%) of cases done in the operating room using a Datex-Ohmeda monitor vs. 183 (27.5%) of cases in the operating rooms using Phillips monitors (P = 0.005). In multivariable logistic regression analysis, the relative odds of the occurrence of monitoring gaps was 35% higher in rooms with the Phillips BP monitors as compared to the Datex-Ohmeda monitor while controlling for pre-specified covariates (odds ratio = 1.35, 95% confidence interval = 1.04–1.74, P = 0.02). Conclusion The present analysis suggests that aberrant BP readings for parturients undergoing caesarean delivery are significantly different between the two types of automated BP monitoring systems used in the operating rooms at our institution. Received 15 July 2020 Accepted 22 September 2020 Correspondence to Robert B. Schonberger, MD MHS, Department of Anesthesiology, Yale School of Medicine, TMP-3, 333 Cedar Street, P.O. Box 208051, New Haven, CT 06520-8051, USA, Tel: +203 785 2802; fax: +203 785 6664; e-mail: robert.schonberger@yale.edu Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

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