Hypertension: Myers MG

Padwal RS, Hemmelgarn BR, Khan NA, Grover S, McKay DW, Wilson T, Penner B, Burgess E, McAlister FA, Bolli P, Hill MD, Mahon J, Myers MG, Abbott C, Schiffrin EL, Honos G, Mann K, Tremblay G, Milot A, Cloutier L, Chockalingam A, Rabkin SW, Dawes M, Touyz RM, Bell C, Burns KD, Ruzicka M, Campbell NR, Vallée M, Prasad R, Lebel M, Tobe SW, Anonymous00149. · Division of General Internal Medicine, University of Alberta, Edmonton, Canada. · Can J Cardiol. · Pubmed #19417858 No free full text.

Abstract: OBJECTIVE: To provide updated, evidence-based recommendations for the diagnosis and assessment of adults with hypertension. OPTIONS AND OUTCOMES: The diagnosis of hypertension is dependent on appropriate blood pressure measurement, the timely assessment of serially elevated readings, the degree of blood pressure elevation, the method of measurement (office, ambulatory, home) and associated comorbidities. The presence of cardiovascular risk factors and target organ damage should be ascertained to assess global cardiovascular risk and determine the urgency, intensity and type of treatment required. EVIDENCE: MEDLINE searches were conducted from November 2007 to October 2008 with the aid of a medical librarian. Reference lists were scanned, experts were contacted, and the personal files of authors and subgroup members were used to identify additional studies. Content and methodological experts assessed studies using prespecified, standardized evidence-based algorithms. Recommendations were based on evidence from peer-reviewed full-text articles only. RECOMMENDATIONS: Recommendations for blood pressure measurement, criteria for hypertension diagnosis and follow-up, assessment of global cardiovascular risk, diagnostic testing, diagnosis of renovascular and endocrine causes of hypertension, home and ambulatory monitoring, and the use of echocardiography in hypertensive individuals are outlined. Key messages include continued emphasis on the expedited, accurate diagnosis of hypertension, the importance of global risk assessment and the need for ongoing monitoring of hypertensive patients to identify incident type 2 diabetes. VALIDATION: All recommendations were graded according to strength of the evidence and voted on by the 57 members of the Canadian Hypertension Education Program Evidence-Based Recommendations Task Force. All recommendations were required to be supported by at least 70% of task force members. These guidelines will continue to be updated annually.

Padwal RS, Hemmelgarn BR, McAlister FA, McKay DW, Grover S, Wilson T, Penner B, Burgess E, Bolli P, Hill M, Mahon J, Myers MG, Abbott C, Schiffrin EL, Honos G, Mann K, Tremblay G, Milot A, Cloutier L, Chockalingam A, Khan NA, Rabkin SW, Dawes M, Touyz RM, Tobe SW, Anonymous00038. · Division of General Internal Medicine, University of Alberta, Edmonton, Alberta. · Can J Cardiol. · Pubmed #17534459 links to  free full text

Abstract: OBJECTIVE: To provide updated, evidence-based recommendations for the diagnosis and assessment of adults with hypertension. OPTIONS AND OUTCOMES: The diagnosis of hypertension is dependent on the appropriate measurement of blood pressure, the timely assessment of serially elevated readings, the degree of blood pressure elevation, the method of measurement (office, ambulatory, home) and any associated comorbidities. The presence of cardiovascular risk factors and target organ damage should be ascertained to assess global cardiovascular risk, and to determine the urgency, intensity and type of treatment required. EVIDENCE: MEDLINE searches were conducted from November 2005 to October 2006 with the aid of a medical librarian. Reference lists were scanned, experts were contacted, and the personal files of authors and subgroup members were used to identify additional studies. Content and methodological experts assessed studies using prespecified, standardized evidence-based algorithms. Recommendations were based on evidence from peer-reviewed, full-text articles only. RECOMMENDATIONS: Recommendations for blood pressure measurement, criteria for hypertension diagnosis and follow-up, assessment of global cardiovascular risk, diagnostic testing, diagnosis of renovascular and endocrine causes of hypertension, home and ambulatory monitoring, and the use of echocardiography in hypertensive individuals are outlined. Key messages in 2007 include continued emphasis on the expedited, accurate diagnosis of hypertension, the importance of assessing the risk of cerebrovascular events as part of global risk assessment, the need for ongoing reassessment of patients with high normal blood pressure, and reviews of recent studies involving laboratory testing and home monitoring. VALIDATION: All recommendations were graded according to strength of the evidence and were voted on by the 57 members of the Canadian Hypertension Education Program Evidence-Based Recommendations Task Force. All recommendations reported here received at least 70% consensus. These guidelines will continue to be updated annually.

Hemmelgarn BR, McAlister FA, Grover S, Myers MG, McKay DW, Bolli P, Abbott C, Schiffrin EL, Honos G, Burgess E, Mann K, Wilson T, Penner B, Tremblay G, Milot A, Chockalingam A, Touyz RM, Tobe SW, Anonymous00011. · Division of Nephrology, University of Calgary, and Foothills Hospital, 1403 29th Street Northwest, Calgary, Alberta, Canada. · Can J Cardiol. · Pubmed #16755312 links to  free full text

Abstract: OBJECTIVE: To provide updated, evidence-based recommendations for the diagnosis and assessment of adults with high blood pressure. OPTIONS AND OUTCOMES: For persons in whom a high blood pressure value is recorded, a diagnosis of hypertension is dependent on the appropriate measurement of blood pressure, the level of the blood pressure elevation, the approach used to monitor blood pressure (office, ambulatory or home/self), and the duration of follow-up. In addition, the presence of cardiovascular risk factors and target organ damage should be assessed to determine the urgency, intensity and type of treatment. For persons diagnosed as having hypertension, estimating the overall risk of adverse cardiovascular outcomes requires an assessment for other vascular risk factors and hypertensive target organ damage. EVIDENCE: MEDLINE searches were conducted from November 2004 to October 2005 to update the 2005 recommendations. Reference lists were scanned, experts were polled, and the personal files of the authors and subgroup members were used to identify other studies. Identified articles were reviewed and appraised using prespecified levels of evidence by content and methodological experts. As per previous years, the authors only included studies that had been published in the peer-reviewed literature and did not include evidence from abstracts, conference presentations or unpublished personal communications. RECOMMENDATIONS: The present document contains recommendations for blood pressure measurement, diagnosis of hypertension, and assessment of cardiovascular risk for adults with high blood pressure. These include the accurate measurement of blood pressure, criteria for the diagnosis of hypertension and recommendations for follow-up, assessment of overall cardiovascular risk, routine and optional laboratory testing, assessment for renovascular and endocrine causes, home and ambulatory blood pressure monitoring, and the role of echocardiography for those with hypertension. Key features of the 2006 recommendations include continued emphasis on an expedited diagnosis of hypertension, an in-depth review of the role of global risk assessment in hypertension therapy, and the use of home/self blood pressure monitoring for patients with masked hypertension (subjects with hypertension who have a blood pressure that is normal in clinic but elevated on home/self measurement). VALIDATION: All recommendations were graded according to the strength of the evidence and were voted on by the 45 members of the Canadian Hypertension Education Program Evidence-Based Recommendations Task Force. All recommendations reported herein received at least 95% consensus. These guidelines will continue to be updated annually.

Myers MG, Tobe SW, McKay DW, Bolli P, Hemmelgarn BR, McAlister FA, Anonymous00046. · Division of Cardiology, Sunnybrook & Women's Health Sciences Centre, Toronto, Ontario, Canada. · Am J Hypertens. · Pubmed #16202864 No free full text.

Abstract: Most national and international guidelines for diagnosing hypertension include 24-h ambulatory blood pressure monitoring (ABPM) and self (home) BP monitoring (SBPM) as optional methods for identifying hypertensive patients. However, none of the current guidelines have yet included ABPM or SBPM as fundamental tools for diagnosing hypertension, preferring instead to rely on conventional office readings recorded by mercury sphygmomanometry. During the past 10 years, clinical outcome studies have consistently reported 24-h ABPM and SBPM to be significantly better predictors of cardiovascular events compared with the office BP, even when recorded under "research conditions." Based on the available evidence, the Canadian Hypertension Education Program has now developed an algorithm for diagnosing hypertension that offers three options: 1) conventional office BP, 2) SBPM, or 3) 24-h ABPM. Out-of-office BP measurements are recommended, whenever feasible, to minimize both measurement error associated with mercury sphygmomanometry and the white coat effect experienced by some patients.

Hemmelgarn BR, McAllister FA, Myers MG, McKay DW, Bolli P, Abbott C, Schiffrin EL, Grover S, Honos G, Lebel M, Mann K, Wilson T, Penner B, Tremblay G, Tobe SW, Feldman RD, Anonymous00236. · Division of Nephrology, University of Calgary, Calgary, Canada. · Can J Cardiol. · Pubmed #16003448 links to  free full text

Abstract: OBJECTIVE: To provide updated, evidence-based recommendations for the diagnosis and assessment of adults with high blood pressure (BP). OPTIONS AND OUTCOMES: For persons in whom a high BP value is recorded, the assignment of a diagnosis of hypertension is dependent on the appropriate measurement of BP, the level of the BP elevation and the duration of follow-up. In addition, the presence of cardiovascular risk factors and target organ damage should be assessed to determine the urgency, intensity and type of treatment. For persons diagnosed as having hypertension, estimating overall risk of adverse cardiovascular outcomes requires an assessment of other vascular risk factors and hypertensive target organ damage. EVIDENCE: MEDLINE searches were conducted from November 2003 to October 2004 to update the 2004 recommendations. Reference lists were scanned, experts were polled, and the personal files of the authors and subgroup members were used to identify other studies. Identified articles were reviewed and appraised using prespecified levels of evidence by content and methodological experts. As per previous years, only studies that had been published in the peer-reviewed literature were included; evidence from abstracts, conference presentations and unpublished personal communications was not included. RECOMMENDATIONS: This document contains recommendations for BP measurement, diagnosis of hypertension and assessment of cardiovascular risk for adults with high BP. These include the accurate measurement of BP, criteria for diagnosis of hypertension, and recommendations for follow-up, assessment of overall cardiovascular risk, routine and optional laboratory testing, assessment for renovascular and endocrine causes, home and ambulatory BP monitoring, and the role of echocardiography for those with hypertension. Key features of the 2005 recommendations include an expedited diagnostic algorithm for hypertension and an endorsement of the use of home/self and ambulatory BP assessment as validated techniques in establishing the diagnosis of hypertension. VALIDATION: All recommendations were graded according to the strength of the evidence and voted on by the 43 members of the Canadian Hypertension Education Program Evidence-Based Recommendations Task Force. All recommendations reported in the present paper received at least 95% consensus. These guidelines will continue to be updated annually.

Hemmelgarn BR, Zarnke KB, Campbell NR, Feldman RD, McKay DW, McAlister FA, Khan N, Schiffrin EL, Myers MG, Bolli P, Honos G, Lebel M, Levine M, Padwal R, Anonymous00144. · Division of Nephrology, University of Calgary, Calgary, Canada. · Can J Cardiol. · Pubmed #14968141 links to  free full text

Abstract: OBJECTIVE: To provide updated, evidence-based recommendations for the assessment of the diagnosis, cardiovascular risk and identifiable causes for adults with high blood pressure. OPTIONS: For persons in whom a high blood pressure value is recorded, the assignment of a diagnosis of hypertension is dependent on the appropriate measurement of blood pressure, the level of the blood pressure elevation and the duration of follow-up. In addition, the presence of concomitant vascular risk factors, target organ damage and established atherosclerotic diseases should be assessed to determine the urgency, intensity and type of treatment. For persons diagnosed as having hypertension, defining overall risk of adverse cardiovascular outcomes requires an assessment of concomitant vascular risk factors, including laboratory testing, a search for target organ damage and an assessment for modifiable causes of hypertension. Home and ambulatory blood pressure assessment and echocardiography are options for selected patients. OUTCOMES: The identification of persons at increased risk of adverse cardiovascular outcomes; the quantification of overall cardiovascular risk; and the identification of persons with potentially modifiable causes of hypertension. EVIDENCE: Medline searches were conducted from November 2001, one year before the period of the last revision of the Canadian recommendations for the management of hypertension, to October 2003. Reference lists were scanned, experts were polled, and the personal files of subgroup members and authors were used to identify other studies. Identified articles were reviewed and appraised using prespecified levels of evidence by content experts and methodological experts. VALUES: A high value was placed on the identification of persons at increased risk of cardiovascular morbidity and mortality, and persons with identifiable and potentially modifiable causes of hypertension. BENEFITS, HARMS AND COSTS: The identification of persons at higher risk of cardiovascular disease will permit counselling for lifestyle maneuvers and introduction of antihypertensive drugs to reduce blood pressure for patients with sustained hypertension. The identification of specific causes of hypertension may permit the use of cause-specific interventions. For certain subgroups of patients and specific classes of drugs, blood pressure lowering has been associated with reduced cardiovascular morbidity and/or mortality. RECOMMENDATIONS: The document contains recommendations for blood pressure measurement, diagnosis of hypertension and assessment of cardiovascular risk for adults with high blood pressure. These include the accurate measurement of blood pressure, criteria for diagnosis of hypertension, and recommendations for follow-up, assessment of overall cardiovascular risk, routine and optional laboratory testing, assessment for renovascular and endocrine causes, home and ambulatory blood pressure monitoring, and the role of echocardiography for those with hypertension. VALIDATION: All recommendations were graded according to strength of evidence and voted on by the Canadian Hypertension Education Program Evidence-Based Recommendations Task Force. Only the recommendations that achieved high levels of consensus are reported. These guidelines will be updated annually.

Zarnke KB, McAlister FA, Campbell NR, Levine M, Schiffrin EL, Grover S, McKay DW, Myers MG, Wilson TW, Rabkin SW, Feldman RD, Burgess E, Bolli P, Honos G, Lebel M, Mann K, Abbott C, Tobe S, Petrella R, Touyz RM, Anonymous00073. · London Health Sciences Centre, University Hospital Campus, London, Canada. · Can J Cardiol. · Pubmed #12107419 links to  free full text

Abstract: OBJECTIVE: To provide updated, evidence-based recommendations for the assessment of the diagnosis, cardiovascular risk, identifiable causes and lifestyle modifications for adults with high blood pressure. OPTIONS: For persons in whom a high blood pressure value is recorded, hypertension is diagnosed based on the appropriate measurement of blood pressure, the level of the blood pressure elevation and the duration of follow-up. In addition, the presence of concomitant vascular risk factors, target organ damage and established atherosclerotic diseases must be assessed to determine the urgency, intensity and type of treatment. For persons receiving a diagnosis of hypertension, defining the overall risk of adverse cardiovascular outcomes requires an assessment of concomitant vascular risk factors, including laboratory testing, a search for target organ damage and an assessment for modifiable causes of hypertension. Home and ambulatory blood pressure assessment and echocardiography are options for selected patients. OUTCOMES: The outcomes were: the identification of persons at increased risk of adverse cardiovascular outcomes; the quantification of overall cardiovascular risk; and the identification of persons with potentially modifiable causes of hypertension. Evidence: Medline searches were conducted from one year before the period of the last revision of the Canadian recommendations for the management of hypertension (May 1999 to May 2001). Reference lists were scanned, experts were polled, and the personal files of the subgroup members and authors were used to identify other studies. Identified articles were reviewed and appraised, using prespecified levels of evidence, by content experts and methodological experts. In addition to an update of the previous year's review, new sections on assessing overall cardiovascular risk and endocrine causes are provided. VALUES: A high value was placed on the identification of persons at increased risk of cardiovascular morbidity and mortality, and of persons with identifiable causes of hypertension. BENEFITS, HARMS AND COSTS: The identification of persons at higher risk of cardiovascular disease will permit counseling for lifestyle manoeuvres and introduction of antihypertensive drugs to reduce blood pressure for patients with sustained hypertension. The identification of specific causes of hypertension may permit the use of cause-specific interventions. In certain subgroups of patients, and for specific classes of drugs, blood pressure lowering has been associated with reduced cardiovascular morbidity or mortality. RECOMMENDATIONS: The present document contains recommendations for the assessment of the diagnosis, cardiovascular risk, identifiable causes and lifestyle modifications for adults with high blood pressure. These include the accurate measurement of blood pressure, criteria for the diagnosis of hypertension and recommendations for follow-up, assessment of overall cardiovascular risk, routine and optional laboratory testing, assessment for renovascular and endocrine causes, home and ambulatory blood pressure monitoring, the role of echocardiography and lifestyle modifications. VALIDATION: All recommendations were graded according to the strength of the evidence and voted on by the Canadian Hypertension Recommendations Working Group. Only those recommendations achieving high levels of consensus are reported. These guidelines will be updated annually. ENDORSEMENT: These guidelines are endorsed by the Canadian Hypertension Society, The Canadian Coalition for High Blood Pressure Prevention and Control, The College of Family Physicians of Canada, The Heart and Stroke Foundation of Canada, The Adult Disease Division and Bureau of Cardio-Respiratory Diseases and Diabetes at the Centre for Chronic Disease Prevention and Control, Health Canada.

Zarnke KB, Levine M, McAlister FA, Campbell NR, Myers MG, McKay DW, Bolli P, Honos G, Lebel M, Mann K, Wilson TW, Abbott C, Tobe S, Burgess E, Rabkin S, Anonymous00281. · Department of Medicine, London Health Sciences Centre, University of Western Ontario, 339 Windermere Road, London, Ontario N6A 5A5, Canada. · Can J Cardiol. · Pubmed #11773936 links to  free full text

Abstract: OBJECTIVE: To provide updated, evidence-based recommendations for the diagnosis and assessment of high blood pressure in adults. OPTIONS: For people with high blood pressure, the assignment of a diagnosis of hypertension depends on the appropriate measurement of blood pressure, the level of the blood pressure elevation, the duration of follow-up and the presence of concomitant vascular risk factors, target organ damage and established atherosclerotic diseases. For people diagnosed with hypertension, defining the overall risk of adverse cardiovascular outcomes requires laboratory testing, a search for target organ damage and an assessment of the modifiable causes of hypertension. Out-of-clinic blood pressure assessment and echocardiography are options for selected patients. OUTCOMES: People at increased risk of adverse cardiovascular outcomes and were identified and quantified. EVIDENCE: Medline searches were conducted from the period of the last revision of the Canadian recommendations for the management of hypertension (May 1998 to October 2000). Reference lists were scanned, experts were polled, and the personal files of the subgroup members and authors were used to identify other studies. All relevant articles were reviewed and appraised, using prespecified levels of evidence, by content experts and methodological experts. VALUES: A high value was placed on the identification of people at increased risk of cardiovascular morbidity and mortality. BENEFITS, HARMS AND COSTS: The identification of people at higher risk of cardiovascular disease will permit counselling for lifestyle manoeuvres and the introduction of antihypertensive drugs to reduce blood pressure for patients with sustained hypertension. In certain settings, and for specific classes of drugs, blood pressure lowering has been associated with reduced cardiovascular morbidity and/or mortality. RECOMMENDATIONS: The present document contains detailed recommendations pertaining to aspects of the diagnosis and assessment of patients with hypertension, including the accurate measurement of blood pressure, criteria for the diagnosis of hypertension and recommendations for follow-up, routine and optional laboratory testing, assessment for renovascular hypertension, home and ambulatory blood pressure monitoring, and the role of echocardiography in hypertension. VALIDATION: All recommendations were graded according to strength of the evidence and voted on by the Canadian Hypertension Recommendations Working Group. Only the recommendations achieving high levels of consensus are reported here. These guidelines will be updated annually. ENDORSEMENT: These recommendations are endorsed by the Canadian Hypertension Society, The Canadian Coalition for High Blood Pressure Prevention and Control, The College of Family Physicians of Canada, The Heart and Stroke Foundation of Canada, The Adult Disease Division and Bureau of Cardio-Respiratory Diseases and Diabetes at the Centre for Chronic Disease Prevention and Control of Health Canada.

Myers MG. · No affiliation provided · Hypertension. · Pubmed #15767465 links to  free full text

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Myers MG. · No affiliation provided · Hypertension. · Pubmed #14967826 links to  free full text

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Myers MG, Parati G. · No affiliation provided · J Hypertens. · Pubmed #14654736 No free full text.

This publication has no abstract.

Myers MG. · Sunnybrook Health Sciences Centre, A-202, 2075 Bayview Avenue, Toronto, Ontario M4N 3M5, Canada. · Curr Hypertens Rep. · Pubmed #18775111 No free full text.

Abstract: During the past 15 years, clinical outcome studies have consistently reported that home and 24-hour ambulatory blood pressure recordings provide a significantly better measure of cardiovascular risk than do manual blood pressure readings taken in the office or clinic. The advent of automated sphygmomanometers that record blood pressure with the patient alone in the examining room will be the next major change in our approach to recording blood pressure. These automated devices virtually eliminate the white coat response and their readings correlate significantly better with the ambulatory blood pressure compared with manual office blood pressure readings. The principal finding from recent research into automated blood pressure measurement is that the presence of an observer during the actual reading in itself provokes the white coat response.

Padwal RJ, Hemmelgarn BR, Khan NA, Grover S, McAlister FA, McKay DW, Wilson T, Penner B, Burgess E, Bolli P, Hill MD, Mahon J, Myers MG, Abbott C, Schiffrin EL, Honos G, Mann K, Tremblay G, Milot A, Cloutier L, Chockalingam A, Rabkin SW, Dawes MD, Touyz RM, Bell C, Burns KD, Ruzicka M, Campbell NR, Lebel M, Tobe SW, Anonymous00045. · Division of General Internal Medicine, University of Alberta, Edmonton, Canada. · Can J Cardiol. · Pubmed #18548142 links to  free full text

Abstract: OBJECTIVE: To provide updated, evidence-based recommendations for the diagnosis and assessment of adults with hypertension. OPTIONS AND OUTCOMES: The diagnosis of hypertension is dependent on appropriate blood pressure measurement, the timely assessment of serially elevated readings, degree of blood pressure elevation, method of measurement (office, ambulatory, home) and associated comorbidities. The presence of cardiovascular risk factors and target organ damage should be ascertained to assess global cardiovascular risk and determine the urgency, intensity and type of treatment required. EVIDENCE: MEDLINE searches were conducted from November 2006 to October 2007 with the aid of a medical librarian. Reference lists were scanned, experts were contacted, and the personal files of authors and subgroup members were used to identify additional studies. Content and methodological experts assessed studies using prespecified, standardized evidence-based algorithms. Recommendations were based on evidence from peer-reviewed, full-text articles only. RECOMMENDATIONS: Recommendations for blood pressure measurement, criteria for hypertension diagnosis and follow-up, assessment of global cardiovascular risk, diagnostic testing, diagnosis of renovascular and endocrine causes of hypertension, home and ambulatory monitoring, and the use of echocardiography in hypertensive individuals are outlined. Key messages in 2008 include continued emphasis on the expedited, accurate diagnosis of hypertension, the importance of global risk assessment and the need for ongoing monitoring of hypertensive patients to identify incident type 2 diabetes. VALIDATION: All recommendations were graded according to strength of the evidence and voted on by the 57 members of the Canadian Hypertension Education Program Evidence-Based Recommendations Task Force. All recommendations reported here received at least 70% consensus. These guidelines will continue to be updated annually.

Bolli P, Hemmelgarn B, Myers MG, McKay D, Tremblay G, Tobe SW, Anonymous00041. · Ambulatory Internal Medicine Teaching Clinic, St Catharines, Ontario. · Can J Cardiol. · Pubmed #17534467 links to  free full text

Abstract: Subjects with high normal blood pressure are at high risk of developing hypertension. Thus, the criteria of the Canadian Hypertension Education Program for diagnosis of hypertension and recommendations for follow-up now recommend that patients with high normal blood pressure (130 mmHg to 139 mmHg systolic and/or 85 mmHg to 89 mmHg diastolic) be followed up annually for the development of hypertension. Clinical trial data from subjects with high normal blood pressure show that 40% over two years and 63% over four years developed hypertension (140/90 mmHg or higher). These data are consistent with observational data from the Framingham Heart Study, which found a similar risk. Besides annual follow-up, the Canadian Hypertension Education Program recommends lifestyle therapy for individuals with high normal blood pressure. Ongoing research will establish whether any further management is required.

Myers MG, Godwin M. · Shulech Heart Centre, Sunnybrook Health Sciences Centre and the Department of Medicine, University of Toronto, Ontario, Canada. · J Clin Hypertens (Greenwich). · Pubmed #17396069 No free full text.

Abstract: In recent years, automated devices have been developed to record blood pressure (BP) accurately in the home and during usual daily activities. Clinical outcome studies have clearly shown home BP and 24-hour ambulatory BP to be significantly better predictors of future cardiovascular events compared with BP recorded in the office setting using mercury sphygmomanometry. It is also now possible to measure office BP with the patient resting quietly alone in the examining room using an automated device. Studies in routine clinical practice using this approach have demonstrated that automated office BP can eliminate most of the white coat effect seen with manual BP measurement. The automated office BP also correlates significantly better than does the routine office BP with the 24-hour ambulatory BP, the gold standard for predicting risk of future cardiovascular events. Sufficient evidence now exists to consider incorporating automated office BP into an algorithm for diagnosing hypertension.

McKay DW, Myers MG, Bolli P, Chockalingam A. · Division of Basic Medical Sciences, Faculty of Medicine, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada. · Can J Cardiol. · Pubmed #16755318 links to  free full text

Abstract: A patient has masked hypertension when his office blood pressure is less than 140/90 mmHg but his ambulatory or home blood pressure readings are in the hypertensive range. Several recent studies have demonstrated that cardiovascular risk is similar between those with masked hypertension and those with sustained hypertension. The prevalence of masked hypertension in Canada is not known, but data from other countries suggest rates greater than 8%. Physicians need to use careful clinical judgment to identify and treat subjects with masked hypertension. The present review discusses masked hypertension, its importance to clinical practice and some aspects of patient management.

Myers MG. · Sunnybrook and Women's College Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, Ontario M4N 3M5, Canada. · Can J Cardiol. · Pubmed #15614335 links to  free full text

Abstract: During the past few years, 24 h ambulatory blood pressure (BP) monitoring has become an essential tool in the management of hypertensive patients. Individuals who exhibit increases in BP only in the office setting (white coat hypertension) can now avoid unnecessary drug therapy. For patients with treated hypertension, ambulatory BP monitoring has provided a means to detect individuals at increased risk of experiencing a cardiovascular event independent of the office BP reading. Alternatives to BP monitoring, such as self-measurement in the home, do exist, but the interpretation of findings reported by patients must be scrutinized carefully to take into account the use of nonvalidated devices and the possibility of "reporting bias". Automated BP recording devices have recently been introduced into the office setting and are likely to become more commonplace over the next few years. The Canadian Hypertension Education Program recommends the assessment of hypertensive patients with ambulatory BP monitoring in accordance with specific guidelines for the diagnosis of hypertension and the detection of a white coat effect in treated patients who are having difficulty reaching target BP levels.

Myers MG. · Division of Cardiology, Sunnybrook, Women's College Health Sciences Centre, Department of Medicine, University of Toronto, Toronto, Canada. · Blood Press Monit. · Pubmed #15564980 No free full text.

Abstract: Current hypertension guidelines continue to base management decisions on the office BP as recorded by mercury sphygmomanometry. The imminent disappearance of mercury from the workplace for environmental and safety reasons provides an opportunity to re-assess how a diagnosis of hypertension is made. There are now several validated, automated BP recording devices available to replace mercury sphygmomanometers in the office setting. Self/home and 24-hour ambulatory BP monitoring should now become an integral part of the diagnostic algorithm for hypertension in view of their superior ability to predict clinical outcomes when compared to traditional office BP measurements.

Myers MG. · Division of Cardiology, Sunnybrook and Women's College Health Sciences Centre, 2075 Bayview Avenue, Suite A332, Toronto, Ontario M4N 3M5, Canada. · Heart Dis. · Pubmed #11728257 No free full text.

Abstract: The sixth report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of Hypertension report has recommended long-acting, once-daily drugs as preferred therapy for the management of hypertension. The duration of action of an antihypertensive agent can be assessed in several ways. The decrease in clinical blood pressure at the end of the dosing interval has traditionally been the method for determining antihypertensive efficacy. However, this approach does not provide information about a drug's effects over the remainder of the 24-hour dosing interval. The trough-to-peak ratio has been proposed as an arithmetic index of a compound's maximum and minimum antihypertensive effects. This ratio can be obtained from multiple readings in an office setting or using data from 24-hour ambulatory blood-pressure monitoring. A simplified approach has been to compare a single office reading at the time of a drug's known maximum antihypertensive effect (peak) with the reduction in blood pressure at 24 hours (trough). Office readings have also been used to show that the same dose of a drug given once daily versus twice daily results in a similar trough blood pressure, confirming that once-daily therapy is appropriate. The 24-hour ambulatory blood pressure can be used to determine mean changes in daytime, evening, and night-time blood pressure to demonstrate the antihypertensive profile over the entire dosing interval. Finally, the finding of a persistent reduction in ambulatory blood pressure following substitution of placebo for an antihypertensive drug during chronic therapy (missed-dose technique) suggests that a compound decreases blood pressure for 48 hours or longer. Thus, it should be possible to demonstrate the effectiveness of once-daily antihypertensive therapy using one or more of the aforementioned methods.

Myers MG, Valdivieso MA. · Division of Cardiology, Schulich Heart Centre, Sunnybrook and Women's College Health Sciences Centre, Toronto, Ontario, Canada. · Am J Hypertens. · Pubmed #12799100 No free full text.

Abstract: BACKGROUND: Patients often exhibit higher blood pressure (BP) readings in the doctor's office, a phenomenon known as the white coat effect. This study examines the presence of a physician in the examining room as a possible factor in provoking a white coat effect. METHODS: Blood pressure measurements taken by an automated BP recording device, the BpTRU (VSM MedTech Ltd., Vancouver, BC, Canada) with the patient alone in the examining room, were compared with the following: (1) BP taken by the patient's family physician; (2) BP taken on the first visit to a hypertension specialist; (3) BP measured by a trained research technician and (4) the mean awake ambulatory BP (ABP). The BpTRU and trained research technician readings were taken outside of the office (treatment) setting in an ABP research unit. RESULTS: Blood pressure readings (mm Hg, mean +/- SEM) taken by the BpTRU (155 +/- 5/88 +/- 2) tended to be lower than for the family physician (166 +/- 4/89 +/- 3) and the hypertension specialist (174 +/- 5/92 +/- 2; P <.001). However, BP taken by the trained research technician (158 +/- 4/90 +/- 2) was similar to the value obtained by the BpTRU. The mean awake ABP was lower (P < 0.01) than the other four BP values. CONCLUSIONS: Use of an automated BP recording device outside of the office (treatment) setting can partly eliminate the white coat effect. A similar finding was observed with readings taken by a trained research technician under similar conditions. Referral of patients to nonoffice settings for automated BP recordings may provide a more accurate estimate of a patient's BP status, with partial elimination of the white coat effect associated with readings taken by a physician.

Leenen FH, Myers MG, Joyner CD, Toal CB. · University of Ottawa Heart Institute, Canada. · Can J Cardiol. · Pubmed #12518180 links to  free full text

Abstract: BACKGROUND: Recent meta-analyses suggest that once-daily dihydropyridines and angiotensin-converting enzyme inhibitors cause similar decreases in left ventricular (LV) mass for comparable decreases in blood pressure (BP). However, some dihydropyridines, such as felodipine-extended release (ER), still increase sympathetic activity and may, therefore, be less effective in decreasing LV mass. OBJECTIVES: To evaluate the effects of long term antihypertensive treatment with nifedipine-gastrointestinal therapeutic system (GITS) and felodipine-ER compared with enalapril on LV mass relative to the extent of BP control (assessed by 24 h ambulatory BP monitoring) and sympathetic activity (assessed by plasma catecholamine concentrations). PATIENTS AND METHODS: Enalapril was started at 10 mg/day, felodipine-ER at 5 mg/day and nifedipine-GITS at 30 mg/day, all once daily. Doses were increased to 20 mg/day, 10 mg/day or 60 mg/day, respectively, if the office BP remained 160/90 mmHg or greater at the end of the dosing interval. Evaluable echocardiograms were obtained for 116 patients at the end of the study (30 weeks of treatment). RESULTS: On 24 h ambulatory BP monitoring, nifedipine-GITS caused a consistent decrease in BP throughout the 24 h dosing interval, whereas felodipine-ER caused a more marked fall in BP during the day, and enalapril's effects diminished during the night and had disappeared by the morning. Only felodipine-ER significantly increased supine and standing plasma noradrenaline by more than 50% similarly after six, 18, and 30 weeks of treatment. In BP responders (decrease in systolic BP 10 mmHg or greater), enalapril and nifedipine-GITS caused clear decreases in LV mass by 12 to 16 g/m2, whereas felodipine-ER was less effective (decrease by only 6 g/m2, P<0.01 versus enalapril). CONCLUSIONS: Once-daily dihydropyridines should not be regarded as one homogeneous class and, compared with felodipine-ER, nifedipine-GITS exhibits a better profile regarding 24 h BP control, sympathetic activation and regression of LV mass.

Safar ME, Myers MG, Leenen F, Asmar R. · Medecine Interne 1, Hôpital Broussais, Paris, France. · J Hypertens. · Pubmed #12172328 No free full text.

Abstract: BACKGROUND : Dose-ranging of antihypertensive agents have been done to optimize diastolic blood pressure (DBP) reduction, but with little information on systolic (SBP), mean (MBP), or pulse (PP) pressures. A low-dose combination of perindopril (Per) and indapamide (Ind) has been shown to reduce more SBP than atenolol for the same DBP reduction. However, the possible influence of gender on this finding has never been tested. PURPOSE : A database of five randomized, double-blind, dose-ranging studies was established to determine the optimal dose of the Per/Ind combination in hypertensive men and women. A total of 2907 patients were treated by either placebo or various combinations associating Per (2, 4, 8 mg) and Ind (0.625, 1.25, 2.5 mg). RESULTS : In the overall population, there was a significant dose-response relationship (P < 0.001) for doubling the dose of Per 2/Ind 0.625 mg up to Per 8/Ind 2.5 mg with a progressive fall in SBP, DBP, MBP. When men and women were analyzed by dose, SBP, DBP and MBP (but not PP) decreased significantly more in women than in men until the Per 4/Ind 1.25 dosage was reached. Thereafter, with higher dosages, generating a slight but significant hypokalemia, the finding was reversed, resulting in a gender interaction in the overall population. CONCLUSION : In hypertensive subjects, the low-dose combinations Per 2/Ind 0.625 and Per 4/Ind 1.25 are the most effective in reducing blood pressure and avoiding hypokalemia. This effect is more pronounced in women, in which increased SBP and PP are predominant hemodynamic features.

Lewis JE, Boyle E, Magharious L, Myers MG. · Sunnybrook & Women's College Health Sciences Centre, and Department of Family and Community Medicine, University of Toronto, Ontario. · CMAJ. · Pubmed #12000246 links to  free full text

Abstract: BACKGROUND: Automated devices are widely available in the community for people to measure their blood pressure. We assessed the accuracy and reproducibility of a brand of community-based automated device against the standard mercury sphygmomanometer. METHODS: Same-arm pairs of blood pressure readings were obtained with the Vita-Stat 90550 automated device, a sphygmomanometer and the Omron HEM-705CP automated device in random order on volunteers in 3 community pharmacies using a modified protocol for evaluating blood pressure devices. Comparison of readings between the Omron device and the sphygmomanometer served as a positive control of how well a laboratory-validated automated device could perform in the community. Both the Association for the Advancement of Medical Instrumentation (AAMI) and British Hypertension Society (BHS) criteria were used to assess the accuracy and reproducibility of readings. RESULTS: The mean blood pressure reading and standard error (SE) of the mean for the 108 volunteers (66 women and 42 men) was 133/77 (SE 2/1) mm Hg with the Vita-Stat device, 131/77 (SE 2/1) mm Hg with the Omron device and 129/76 (SE 2/1) mm Hg with the sphygmomanometer. The mean difference in readings was 4.4/1.0 (standard deviation [SD] 9.4/6.2) mm Hg between the Vita-Stat device and the sphygmomanometer and 1.6/0.6 (SD 9.3/6.4) mm Hg between the Omron device and the sphygmomanometer. Neither automated device met the AAMI accuracy criteria for the systolic readings. The BHS grades were C/A (systolic unacceptable/diastolic acceptable) for each automated device. According to the BHS analytical criterion, all devices achieved acceptable reproducibility grades. INTERPRETATION: Neither automated device met the AAMI or BHS criteria for accuracy while in use in the community, and neither performed as well in the community as in the laboratory.

Myers MG, Valdivieso M, Kiss A. · Schulich Heart Centre, Department of Medicine, University of Toronto, Toronto, Ontario, Canada. · Blood Press Monit. · Pubmed #19417634 No free full text.

Abstract: OBJECTIVE: Conventional office blood pressure (BP) readings are affected by various factors including the presence of an observer and the setting. This study was undertaken to assess the consistency of automated self-measurement of BP in the office during repeat visits and in different settings. Automated office BP readings were also compared with the mean awake ambulatory BP. METHODS: BP readings were obtained using an automated BpTRU sphygmomanometer during routine visits to a hypertension specialist before and after 24-h ambulatory BP monitoring (ABPM) was performed. A third automated BP reading was obtained during the visit to the ABPM unit. RESULTS: There were no significant differences among the three automated office BP readings, which were all similar to the mean awake ambulatory BP. A manual BP reading taken by the ABPM technician was significantly higher (P<0.001) than the mean awake ambulatory BP. There was good agreement among the three automated office BP readings (intraclass correlation coefficient for systolic/diastolic BP r = 0.896/0.873). CONCLUSION: Mean automated office BP readings are consistent from visit-to-visit regardless of the setting in which they are taken and they are similar to the mean awake ambulatory BP.

Myers MG, Valdivieso M, Kiss A, Tobe SW. · Division of Cardiology, Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada. · Blood Press Monit. · Pubmed #19190490 No free full text.

Abstract: OBJECTIVE: To compare readings obtained using two automated blood pressure (BP) recording devices, BpTRU and Omron 907, in a clinical setting. METHODS: Two series of 50 patients attending a hypertension unit for 24-h ambulatory BP monitoring had BP recorded either every 1 or every 2 min using BpTRU and Omron 907 devices with the order of the measurements being randomized. RESULTS: No significant differences for systolic BP between the mean readings taken using the BpTRU or Omron 907 recorders at either 1 or 2 min were observed. Diastolic BP readings were similar using the 1-min interval setting but were 5.0 mmHg lower for the Omron 907 (P<0.001) when readings were taken at 2-min intervals. CONCLUSION: BP measurements can be made in the clinical setting using either the BpTRU or Omron 907 automated sphygmomanometers.