Blood pressure measurements, patterns, and targets

Zanchetti, Alberto

doi: 10.1097/HJH.0000000000001248
Editor's Corner

Istituto Auxologico Italiano and Centro Interuniversitario di Fisiologia Clinica e Ipertensione, Università degli Studi di Milano, Milan, Italy

Correspondence to Professor Alberto Zanchetti, Istituto Auxologico Italiano IRCCS and Centro Interuniversitario di Fisiologia Clinica e Ipertensione, Università degli Studi di Milano, Via F. Sforza 35, 20122 Milan, Italy. Tel: +39 02 50320484; e-mail:,

Article Outline

A consistent number of studies published in the current issue of the Journal of Hypertension are focused on different aspects of blood pressure (BP) measurements, such as accuracy and reliability, BP patterns, particularly their relationships with organ damage and renal disease, and BP targets for treatment.

Kallioinen et al. (pp. 421–441) present the results of a systematic review of studies quantifying BP measurement inaccuracy. In total, 27 significant potential sources of inaccuracy were identified as relating to the patient, device, procedure, or observer. Effects of individual sources could be very large, ranging from −23.6 to +33 mmHg for SBP and −14 to +23 mmHg for DBP. The wise conclusion is that, where a measurement is abnormally high or low, further measurements should be taken and averaged, and an interesting suggestion is that, whenever possible, BP should be recorded graphically within ranges. The current interest for measuring central hemodynamic parameters, such as central BP and arterial wave reflection, has led Stoner et al. (pp. 501–505) to investigate the reliability of oscillometric pulse wave analysis devices. They find an acceptable reliability with sufficient precision to detect clinically meaningful changes in backward pressure component and reflection magnitude, especially when the individuals are fasted and in supine position.

Three studies investigate BP patterns, and particularly night-time BP. Kollias et al. (pp. 442–452) have reviewed studies comparing night BP traditionally measured by ambulatory BP monitoring with values obtained by novel low-cost home monitors, and found similar values as well as similar relationships of both types of night measurements with organ damage, such as left ventricular mass, carotid intima–media thickness, and urinary albumin excretion. In an accompanying editorial commentary, Head (pp. 463–465) remarks that a potential advantage of the novel devices allowing night BP measurement at home is that they can provide multiple measurements in different days, what is practically impossible with ambulatory monitoring. The commentary concludes that Kollias et al.'s (pp. 442–452) meta-analysis will be a major stimulus for the development and wider use of nocturnal BP devices. In an analysis of ambulatory BP tracings of the 2021 participants in the population PAMELA study, Cuspidi et al. (pp. 506–512) report that isolated daytime and isolated night-time hypertension are associated with similar left ventricular mass indices, which are intermediate between those in normotension and in day and night hypertension. Cha et al. (pp. 593–601) have examined a cohort of Korean hypertensive patients (n = 378) with hypertension and chronic kidney disease, who had ambulatory BP monitoring at enrolment and 1 year later: a large majority of them had uncontrolled BP and abnormal night-dipping patterns. Improvements in BP control and night dipping after 1 year were associated with more stable estimated glomerular filtration rate and proteinuria changes, as well as less left ventricular hypertrophy.

In a cohort of 152 young adults (mean age = 31 years), 24-h BP variability measured as weighted SD was found to correlate significantly with aortic distensibility measured by magnetic resonance (Boardman et al., pp. 513–522). The authors agree that, BP variability being a recognized cardiovascular risk marker, strategies to measure and protect aortic function from young age may be important to reduce cardiovascular risk. Aortic function is also the object of a study by Murakami et al. (pp. 533–537). These authors recorded aortic pressure waveforms by a pressure sensor-mounted catheter in children after a successful repair of an aortic coarctation, and found pulse pressure was wider than in controls in the ascending but not in the descending aorta, thus indicating the repaired site generated a new pressure wave reflection.

Other studies in this issue are focused on different BP measurements in the management of hypertension. In a randomized study on a cohort of older adults, Tzourio et al. (pp. 612–620) have tested the hypothesis that regular home BP monitoring may lead to a BP reduction in the elderly, and have shown that regular home BP monitoring every 3 months without co-intervention resulted in a slightly but significantly greater BP reduction over 2 years than in the control group.

The problem of the BP target values to be aimed at by treatments is raised again by a study by Fodor et al. (pp. 621–626), who have analyzed data collected 10 years ago in a representative sample of the Ontario population, in which BP was measured with the same method (automatic device, unattended by health personnel) as in the recent Systolic Blood Pressure Intervention Trial (SPRINT) study: in older patients (60–79 years), control (SBP < 140 mmHg) rates were very high (70–85%) and high was also the proportion of old hypertensive patients with a SBP less than 130 mmHg and even less than 120 mmHg. These interesting data are commented in an editorial by Mancia and Kjeldsen (pp. 471–472), who raise the point that major correction factors need to be applied to the unattended automatic office BP values to make them confrontable with those measured in all other randomized trials upon which guidelines have based their target BP recommendations. Unfortunately, studies measuring both conventional and SPRINT-like office BP in larger groups of patients with different demographic and clinical characteristics are unavailable at present. Another study in the current issue of the journal calls for some caution in excessive lowering of BP. In a review of systematic reviews of antihypertensive treatment in patients with diabetes, Brunström et al. (pp. 453–462) report that the effect of antihypertensive treatment on mortality, cardiovascular disease, and coronary heart disease was attenuated at SBP levels lower than 140 mmHg. Taking an achieved BP lower than 140/90 mmHg as a sign of control, Yu et al. (pp. 627–636) have enrolled a large cohort of 10 262 patients with uncontrolled hypertension into a structured multidisciplinary Risk-Assessment-and-Management Programme for patients with Hypertension (RAMP-HT). Comparing RAMP-HT patients with a matched cohort on usual care, RAMP-HT patients were found at target BP (as well as target LDL-cholesterol) in a significantly greater proportion than usual care patients. In discussing these data in an accompanying editorial, De Buyzere and Rietzschel (pp. 473–476) remark that the added value of the RAMP-HT strategy was a better patient-centered in and out-of-office organization and integration of existing multidisciplinary care completed with continuous patient education and feedback loops. They also comment that to narrow the gap between real-world and best clinical care, sustained efforts will be needed by all stakeholders, from physicians, nurses, and patients to public health regulators and political authorities.

Other studies in the current issue of the Journal of Hypertension deal with cardiovascular risk factors, pathophysiologic, and clinical aspects.

Palatini et al. (pp. 487–492) have focused on white-coat and masked tachycardia to investigate whether they are associated with major cardiovascular events and mortality in hypertensive patients. By examining the data of 7602 hypertensive patients who had 24-h ambulatory BP with heart rate monitoring in six prospective studies, they found masked tachycardia, but not white-coat tachycardia, was an independent predictor of cardiovascular events and all-cause mortality, thus confirming that measurement of heart rate adds to cardiovascular risk stratification. In their editorial comment, Hering and Grassi (pp. 468–470) recognize that despite this robust evidence, the clinical use of heart rate as a prognostic index is limited by the lack of data defining the threshold for abnormal values and randomized clinical trials investigating the efficacy of a therapeutic reduction in heart rate on cardiovascular outcomes. Bonnet et al. (pp. 493–500) report analyses from two longitudinal studies of initially normotensive individuals, showing that γ-glutamyltransferase, fatty liver index, and hepatic insulin resistance are associated with incident hypertension. Increasing fasting insulin in obese children and adolescents is reported by Redón et al. (pp. 571–577) to be linked with higher sympathovagal balance and lower cardiorespiratory fitness, independently of the degree of obesity. Although salt intake is widely recognized as an important risk factor for hypertension, its measurement in large epidemiological studies is difficult, as also shown by a large population study in Portugal by Polonia et al. (pp. 477–486), who report a poor agreement between urinary sodium and potassium excretions estimated from spot samples by four different formulas and those measured in 24-h urine collections. The conclusions of Polonia et al. (pp. 477–486) are supported by an accompanying commentary by He (pp. 466–467).

A group of pathophysiological studies include a study by Alesutan et al. (pp. 523–532) on the protective effects of MgCl2 on osteo/chondrogenic transformation of vascular smooth muscle cells and vascular calcification; a study by Funato et al. (pp. 585–592) providing experimental evidence implicating Mg2+ transporter involved in magnesium renal reabsorption in maintaining BP in mice; a study by Koch et al. (pp. 602–611) showing that transient receptor potential vanilloid 2 function regulates cardiac hypertrophy in mice with aortic constriction; a study by Wang et al. (pp. 538–545) finding that overactivation of cannabinoid receptor type I in the rostral ventrolateral medulla promotes cardiovascular responses in spontaneously hypertensive rats (SHR); a study by Stevenson et al. (pp. 546–557) reporting that positive allosteric modulation of hypothalamic GABAA receptors attenuates high BP in Schlager hypertensive mice; and a study by Chen et al. (pp. 558–570) showing that SHR nondippers exhibit poor sleep quality and impaired autonomic functioning to a greater degree than do SHR dippers.

Two other studies deal with clinical problems: Kintis et al. (pp. 578–584) report that patients with resistant hypertension have a higher renal resistive index and a decreased E/A ratio, and Liu et al. (pp. 637–644) publish an epidemiological update of hypertension in Southwest China showing that in the last decade there was an increasing prevalence of hypertension with persisting extremely low levels of awareness, treatment, and control.

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Conflicts of interest

There are no conflicts of interest.

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