Editors Corner
Blood pressure measurements, patterns, and targets
Alberto Zanchetti
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. 421441) 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. 501505) 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 pres-
sure 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. 442452) 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 intimamedia thickness, and urinary albumin
excretion. In an accompanying editorial commentary, Head
(pp. 463465) 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. 442452) 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. 506512) report that isolated daytime and iso-
lated 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. 593601) have examined a
cohort of Korean hypertensive patients (n 378) with
hypertension and chronic kidney disease, who had
Journal of Hypertension
Copyright 2017 Wolters Kluwer Health, Inc. All rights reserved.
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. 513522). The
authors agree that, BP variability being a recognized car-
diovascular 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. 533537). 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. 612620) 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. 621626), 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 (6079 years), control (SBP < 140 mmHg)
rates were very high (7085%) and high was also the
proportion of old hypertensive patients with a SBP less
Journal of Hypertension 2017, 35:419420
Istituto Auxologico Italiano and Centro Interuniversitario di Fisiologia Clinica e Iper-
tensione, Universita` degli Studi di Milano, Milan, Italy
Correspondence to Professor Alberto Zanchetti, Istituto Auxologico Italiano IRCCS
and Centro Interuniversitario di Fisiologia Clinica e Ipertensione, Universita` degli Studi
di Milano, Via F. Sforza 35, 20122 Milan, Italy. Tel: +39 02 50320484;
e-mail: alberto.zanchetti@unimi.it, alberto.zanchetti@auxologico.it
J Hypertens 35:419420 Copyright 2017 Wolters Kluwer Health, Inc. All rights
reserved.
DOI:10.1097/HJH.0000000000001248
www.jhypertension.com 419
Zanchetti
than 130 mmHg and even less than 120 mmHg. These
interesting data are commented in an editorial by Mancia
and Kjeldsen (pp. 471472), 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, Brunstrom et al.
(pp. 453462) report that the effect of antihypertensive
treatment on mortality, cardiovascular disease, and coron-
ary 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. 627636) 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. 473476) 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, patho-
physiologic, and clinical aspects.
Palatini et al. (pp. 487492) 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. 468470) rec-
ognize 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
420 www.jhypertension.com
Copyright 2017 Wolters Kluwer Health, Inc. All rights reserved.
clinical trials investigating the efficacy of a therapeutic
reduction in heart rate on cardiovascular outcomes. Bonnet
et al. (pp. 493500) report analyses from two longitudinal
studies of initially normotensive individuals, showing that
g-glutamyltransferase, fatty liver index, and hepatic insulin
resistance are associated with incident hypertension.
Increasing fasting insulin in obese children and adolescents
is reported by Redon et al. (pp. 571577) 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. 477486), 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 col-
lections. The conclusions of Polonia et al. (pp. 477486) are
supported by an accompanying commentary by He
(pp. 466467).
A group of pathophysiological studies include a study by
Alesutan et al. (pp. 523532) 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. 585592) providing experimental evi-
dence implicating Mg2 transporter involved in magnesium
renal reabsorption in maintaining BP in mice; a study by
Koch et al. (pp. 602611) showing that transient receptor
potential vanilloid 2 function regulates cardiac hypertrophy
in mice with aortic constriction; a study by Wang et al.
(pp. 538545) 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. 546557)
reporting that positive allosteric modulation of hypothala-
mic GABAA receptors attenuates high BP in Schlager hyper-
tensive mice; and a study by Chen et al. (pp. 558570)
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. 578584) report that patients with resistant
hypertension have a higher renal resistive index and a
decreased E/A ratio, and Liu et al. (pp. 637644) publish
an epidemiological update of hypertension in Southwest
China showing that in the last decade there was an increas-
ing prevalence of hypertension with persisting extremely
low levels of awareness, treatment, and control.
ACKNOWLEDGEMENTS
Conflicts of interest
There are no conflicts of interest.
Volume 35  Number 3  March 2017