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Thus, in conclusion, the reproducibility of BP readings, regardless of whether self-measured at home, recorded during ambulatory BP monitoring, or obtained in the office during consultation, deserves attention by clinicians as it has demonstrated important associations with cardiovascular outcomes. The clinical usefulness of BP measurement relies on the commitment and preference of the people in need of these measurements.

Overall acceptance and preference by patients with hypertension were reported to be better for home BP measurement compared with ambulatory BP monitoring [69,70]. These findings were independent of potential characteristics of patients, including previous experience with BP measurement [69]. Conversely, one of the perceived benefits of ambulatory BP monitoring was the shorter duration of the monitoring period only 1-day [70].

Despite the many advantages of ambulatory BP monitoring, excessively frequent cuff inflations cause disruption of sleep, resulting in reduced adherence of patients to repeat the measurements [13]. Recent studies suggest that home BP measurement, particularly nocturnal measurement, is at least as well accepted as ambulatory monitoring, with a trend towards less-severe sleep disturbance [43,48,58,72]. However, the preferences of patients with regard to the number of home BP measurements per night is still not known because different schedules of nocturnal home BP measurements and different questionnaires for assessing patient preferences have been used [48,58,72].

Evidence is accumulating regarding the possibility of cost savings with out-of-office BP compared with conventional clinic BP measurement [73] ; however, no cost-effectiveness analysis on nocturnal home BP has yet been reported at this emerging stage of the method. Ambulatory BP monitors are generally much more expensive than currently available home BP-measuring devices, most of which cost less than Euros. Although clinicians can evaluate hundreds of patients by using the same ambulatory BP monitor, an individual low-cost home BP device enables us to repeatedly measure BP in the daily life of each person.

Moreover, the widespread clinical application of home devices is now being further favoured by currently developing technologies for remote telemonitoring and telemedicine [55,56,74]. For this very reason, nocturnal home BP has the potential to avoid the limited application of nocturnal BP measurement by ambulatory monitoring. Nevertheless, we cannot ignore the initial cost of introducing home devices to each patient.

In a recent meta-analysis [43] , nocturnal home and ambulatory BP measurements were found to be similarly associated with indices of target organ damage i. However, the results [49,59] were from only two studies. Hence, there are still insufficient data comparing the predictive values for target organ damage of nocturnal home and ambulatory BP, and even less is known in relation to cardiovascular events. With regard to pulse wave velocity, Lindroos et al. In relation to hard cardivascular outcomes, which should be the ultimate criterion for considering the usefulness of exposures, available data suggest that nocturnal home BP might have similar prognostic ability compared with nocturnal ambulatory BP; but appropriate outcome studies are needed.

Recent guidelines [1—3,10,21] recommend the use of a validated upper arm cuff oscillometric devices for home BP measurement, and in all the aforementioned studies nocturnal home BP has been measured based on validated upper arm cuff devices Table 1. An upper arm-cuff is generally well aligned with the heart level regardless of whether patients are sitting, standing, or lying on their back [75].

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It would be appropriate to follow the same recommendation when undertaking nocturnal home BP measurements. Furthermore, as one cannot watch a nocturnal measurement during sleep, adequate instruction for the user on the nocturnal home BP methodology by professional staff, including how to fit and remove the device, is highly recommended. Wrist-cuff oscillometric BP measurement devices have been marketed and widely used in clinical practice, particularly for self-measurement of BP during daytime.

Such devices may be acceptable in limited situations, for example, day-to-day monitoring during travel, patients with arm circumferences that are too large or where the upper arm length is too short to apply a large cuff [21] , or — as described later — to measure nocturnal BP during sleep. The measurement-induced reactive rise of home BP values by a wrist-cuff device was reported to be smaller than that by an upper-arm cuff device in hypertensive patients [76] as the wrist-cuff device may cause less discomfort and muscle compression [77].

Nevertheless, there are some problematic aspects related to use of the wrist-cuff devices. One problem is the hydrostatic height-related pressure difference between wrist and heart levels in the lying posture during sleep; a cm hydrostatic pressure difference between the heart level and cuff position results in a 7-mmHg difference in BP levels [78,79].

Even when patients remain in the lateral recumbent position during sleep, the difference in the position between the level of the heart and the mid-arm level is less than that at the wrist level. Another limitation of wrist devices is the different accessibility of radial and ulnar arteries by the device in different people, because of individual anatomical characteristics of the wrist [3,78]. Although wrist position sensors help patients to self-measure their wrist BP more accurately while they are awake [79] , there is no guarantee that even the most advanced wrist-cuff oscillometric device will measure the nocturnal BP accurately during sleep — at least to the level of precision seen with validated upper arm-cuff devices.

Recent studies have used three preset measurements per night [49,53,56] , at fixed times of 2, 3, and 4 h after going to bed [30,58—60,72] , up to six measurements per night at 1-h intervals [48] , or one preset measurement per night with a questionnaire on sleep quality [45,47]. A meta-regression analysis revealed that the differences between home and ambulatory BP was not significantly affected by the number of nocturnal home BP readings [43]. The same research group recently proposed a two-night home BP schedule with three-hourly automated measurements each night as a minimum requirement for the reliable assessment of nocturnal home BP [44].

Although more research is needed on the quality of sleep during nocturnal BP recordings, a single nightly measurement repeated over a relatively long period e. Measuring nocturnal home BP for even just one night, which is the usual approach when using ambulatory BP monitoring, can capture basic information on nocturnal BP level associated with comparably accurate information on quality-of-sleep self-reported over the nocturnal measurement period [45].

This approach does not take advantage of the strengths of multiple nocturnal home measurements, however. The number of nocturnal home BP measurement varied among previous studies Table 1 , and further research is needed to specify optimal nocturnal home BP measurement schedules according to the purpose for which they are performed, including the preference of patients for the frequency of the measurement. This issue must remain open until robust evidence on nocturnal home BP becomes available. Conditions that may affect the nocturnal home BP are listed in Table 2.

Although daytime activities such as smoking, alcohol, and caffeine consumption also affect BP during sleep, the nocturnal home BP offers the advantage of being measured in a relatively controlled condition. Whereas, activities before going to bed along with dietary habits including salt intake — which may be affected by salt sensitivity in individuals [83] — can be influential factors to affect nocturnal BP.

In case of nocturnal home BP measurement, healthcare providers should ask participants to record their activities in a diary, along with the nocturnal home BP values, and should refer to the information in the diary to help guiding clinical decision-making. For research purposes as well as in clinical practice, the use of specific devices e. It is also recommended that sleep quality be recorded by means of self-reporting [45] , applying actigraphy [37] or other methods insofar as possible.

A recent meta-analysis [43] revealed that the nocturnal home and ambulatory BP measurements provide similar values home measurements were 1. Given that the recommended threshold for daytime ambulatory BP is the same as for home BP and that nocturnal home BP levels appear to be similar to nocturnal ambulatory BP, home BP measurement might be a useful and practical alternative to ambulatory BP monitoring in detecting participants with nondipping patterns.

The reported similarity between the home-ambulatory BP agreement [44,58,59] and the agreement between repeated ambulatory BP monitoring in diagnosing a nondipping BP pattern [40,67] also implies that the ambulatory and home BP might be regarded as interchangeable approaches in the detection of nondippers.

Despite the major role that nocturnal ambulatory BP has gained in predicting cardiovascular risk, an important problem remains that the measurement of BP affects sleep quality. The effect on sleep quality is mainly attributed to the disturbance of sleep by cuff inflation. As shown by studies, which combined polysomnography or electroencephalography with nocturnal BP monitoring, cuff inflation was associated with increased arousal and wakefulness [86].

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The BP recording procedure caused a tiny but significant decrease in the slow-wave sleep period and an increase in nocturnal awakening [87]. Brazilian investigators reported that Furthermore, h ambulatory monitoring sometimes causes adverse effects such as pain, skin irritation including upper-arm ecchymoses, and disruption of work [89]. Investigators have reported an inverse association between BP levels and sleep quality.

A lower BP was significantly associated with deeper sleep [34,35]. Although the sleep stage was not changed on electroencephalography, arousal stimuli produced a significant increase in BP 8. A recent report by Oume et al. It is, therefore, a reasonable assumption that cuff inflation induces an increase in BP. Heude et al. In recent studies by Sheshadri et al. SBP increases of 0—10 mmHg were observed in Interestingly, despite the fact that two-thirds of BP measurements caused arousal evaluated by simultaneous electroencephalography, neither the average SBP 1. The addition of noninvasive automatic or semiautomatic BP monitoring did not cause any alterations in the day and night intra-arterial BP or heart rate profiles in a few studies by the Milan group [93—95].

Studies on Brazilian patients [88] and Danish diabetes patients [96] supported the absence of an association between arm-cuff inflation and BP levels, too. However, it is worth noting that bedside monitoring with a catheter represents a different condition from the usual ambulatory setting, although the studies carried out in Milan were based on h intra-arterial ambulatory BP monitoring.

There might be some individual variability in the degree of BP rise triggered by arm-cuff inflations, and that arm-cuff inflation causes a transient reactive increase in BP in some individuals and that the averaging of the nocturnal BP values could mask the elevation that occurs at the precise moment of BP during arousal or cuff inflation.

There are technologic advances in BP device pumps to limit noise during cuff inflation. For example, an innovative, upper arm-cuff inflated by an electric motor drive unit that produces low noise cuff inflation of This device is nearly as quiet as the ABPM Nippon Colin, Komaki; currently Fukuda Colin, Tokyo, Japan [16,91,97] which provided silent inflation; but because of the frequent exchange of a carbon dioxide gas cartridge required for this device, it became impractical and has been discontinued from clinical commercial use.

It is also noteworthy that wrist-cuff devices usually generate less noise because of its small bladder size; for example, the wrist-cuff oscillometric HEMF-N Omron Healthcare, Co. This quiet measurement condition further favors an accurate measurement of BP during the cuff inflation phase [98] as it does not cause the usual loud noise by upper arm-cuff devices that compromises an accurate oscillometric signal capturing during cuff inflation.

A wrist-cuff device may represent a favorable solution for nocturnal home BP measurement with minimal disruption of sleep, an issue which needs to undergo adequate investigation, together with other abovementioned crucial features characterizing wrist-cuff devices for nocturnal BP measurement.

In the clinical setting — as opposed to the research setting — there is room for debate on how to define sleep because of the difficulties in obtaining accurate documentation. The use of the standard narrow-fixed clock intervals with ambulatory BP monitoring, that is, defining the time periods — h as daytime and — h as night-time, has allowed to define the prognostic significance of a rising pattern in nocturnal BP hazard ratio, 1. However, diary record-based classifications provided the best predictive power for stroke incidence hazard ratio 2.

The recall of subjective sleep disturbances during nocturnal home BP measurement [45,47] would be a feasible option to investigate interference with sleep quality, although this approach does not guarantee whether an individual actually remained asleep during the measurement.


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Given the evidence that the quantity and quality of sleep predict cardiovascular outcomes [,] , sleep per se has been indicated as area of interest, together with nocturnal BP, for research in cardiovascular prevention. Hence, there is a need for a convenient and widely available method of determining the state of sleep during BP measurement.

Actigraphy has been used for decades as a tool to screen the state of sleep and to identify people who might benefit from a more precise diagnostic approach through polysomnography [] , that is applicable to either patients [66] and general population [37]. Specific event-triggered BP measurement, such as at the peak of hypoxemia in patients with obstructive sleep apnea patients [31,,] or at the time of the lowest heart rate that may coincide with low levels of sympathetic nervous system activity [] , would be approaches worth considering for research, aimed at improving the clinical relevance of nocturnal home BP measurement.

Such measurements can capture specific episode-related sleep BP surges or declines and may reduce the number of BP readings required during sleep [,]. Moreover, a night-time home BP telemonitoring system has become available by recently marketed devices, such as the Omron HEMG-HP, in which a mobile communication facility is embedded [55,56,74].

Continuous research and development into new home BP devices will enhance the usefulness of night-time home BP measurement in the near future []. In the last two decades, technological advancement in home BP devices have allowed the evaluation of BP also during night-time sleep [7,43]. Preliminary evidence shows that nocturnal home BP measurement is feasible and provides levels of nocturnal BP and ability to detect nondippers similarly as ambulatory BP monitoring does.

Thus, nocturnal home BP measurement might be a practical and reliable alternative to ambulatory BP monitoring, which has been indicated as the gold standard for out-of-office BP measurement but has been limited in its dissemination by practical and economic concerns [5]. Subheadings of the present article represent possible items of a research agenda for future studies on nocturnal home BP Table 3 , among which associations of nocturnal home BP with cardiovascular outcomes are most important.

These research data are needed to guide the implementation of nocturnal home BP measurement in the management of patients with hypertension in clinical practice. Sources of funding: Omron Healthcare Co. The other authors declare no conflicts of interest in association with the present study. You may be trying to access this site from a secured browser on the server. Please enable scripts and reload this page. Wolters Kluwer Health may email you for journal alerts and information, but is committed to maintaining your privacy and will not share your personal information without your express consent.

For more information, please refer to our Privacy Policy. Subscribe to eTOC. Advanced Search. Toggle navigation. Subscribe Register Login. Your Name: optional. Your Email:. Colleague's Email:. Separate multiple e-mails with a ;. Thought you might appreciate this item s I saw at Journal of Hypertension. Send a copy to your email. Some error has occurred while processing your request. Please try after some time. Effect of cuff inflation on blood pressure levels during sl Cuff inflation and sleep quality Cuff inflation and nocturnal blood pressure Pump-inflation noise and nocturnal blood pressure Miscellaneous issues related to nocturnal home blood pressu Back to Top Article Outline.

TABLE 1. TABLE 2. TABLE 3. Hypertension ; e13—e Cited Here View Full Text PubMed. Hypertens Res ; — The Japanese Society of Hypertension guidelines for self-monitoring of blood pressure at home second edition. PubMed CrossRef. Call to action on use and reimbursement for home blood pressure monitoring: a joint scientific statement from the American Heart Association, American Society of Hypertension, and Preventive Cardiovascular Nurses Association. Hypertension ; — Head GA. The importance and prognostic value of nocturnal blood pressure assessments using inexpensive domestic devices. J Hypertens ; — Risk stratification by self-measured home blood pressure across categories of conventional blood pressure: a participant-level meta-analysis.

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Prognostic role of ambulatory blood pressure measurement in patients with nondialysis chronic kidney disease. Arch Intern Med ; — The importance of night-time systolic blood pressure in diabetic patients: Dublin Outcome Study. Increase in nocturnal blood pressure and progression to microalbuminuria in type 1 diabetes. N Engl J Med ; — International Database on Ambulatory blood pressure monitoring in relation to Cardiovascular Outcomes Investigators.

Diagnostic thresholds for ambulatory blood pressure monitoring based on year cardiovascular risk. Circulation ; — Eur Heart J ; — Response to: nocturnal blood pressure dipping: systolic, diastolic or both? Day-night dip and early-morning surge in blood pressure in hypertension: prognostic implications.

Diurnal variation of blood pressure in elderly patients with essential hypertension. J Am Geriatr Soc ; — Loss of nocturnal decline in blood pressure after cardiac transplantation. Reversed dipper blood-pressure pattern is closely related to severe renal and cardiovascular damage in patients with chronic kidney disease. PloS One ; 8:e Altered circadian blood pressure rhythm in patients with Cushing's syndrome.

Exogenous glucocorticoid eliminates or reverses circadian blood pressure variations. Asleep home blood pressure monitoring in obstructive sleep apnea: a pilot study. Blood Press Monit ; — Catheter-based renal denervation reduces hypoxia-triggered nocturnal blood pressure peak in obstructive sleep apnea syndrome. J Clin Hypertens Greenwich ; — Spanish Sleep Network. Ambulatory blood pressure and cardiovascular outcome in relation to perceived sleep deprivation. Effect of measuring ambulatory blood pressure on sleep and on blood pressure during sleep.