Non-invasive blood pressure (BP) measurement is performed by the inflation of an upper-arm cuff, which itself could induce a reactive BP response and potentially influence BP management. The aim of this study was to determine if cuff inflation was associated with reactive BP responses. Beat-to-beat invasive aortic BP was measured continuously before and during inflation of an automated upper-arm cuff in 234 participants (61 ± 10 years, 31% female) undergoing coronary angiography. Reactive responses were calculated as invasive aortic systolic BP immediately post cuff inflation minus baseline aortic systolic BP immediately pre-cuff inflation. Three groups were defined based on an increase (≥ 5 mmHg), decrease (≤ -5 mmHg) or no response (>-5-<5 mmHg) in aortic systolic BP. Cuff inflation was associated with an average increase in aortic systolic BP of 9.8 ± 5.1 mmHg in 28 (12%) participants, an average decrease of 9.2 ± 5.4 mmHg in 43 (18%) participants, and no response in 163 (70%) participants (-0.3 ± 2.4 mmHg). Cuff and baseline aortic systolic BP were higher in participants who exhibited a reactive response and BP variability was greater among the decrease group (ANOVA p < 0.05). No clinical characteristics were associated with reactive responses. Similar findings were observed for diastolic BP, mean arterial pressure and pulse pressure. Approximately one-third of participants exhibited a substantial reactive systolic BP response (increase or decrease) to upper-arm cuff inflation as determined from invasive BP measurements. Whether this could influence the accuracy of cuff BP measures, and consequent hypertension management, should be determined in future, prospectively designed studies.

This cross-sectional study assesses the potential impact of a smartwatch hypertension notification feature for US adults who have not been diagnosed with hypertension.

OBJECTIVES:To evaluate the uptake of a new 60-day dispensing policy for antihypertensive medicines and estimated cost savings compared with conventional 30-day dispensing; and to explore general practitioner and pharmacist perspectives on the new policy. STUDY DESIGN:Mixed methods design; analysis of Pharmaceutical Benefits Scheme (PBS) dispensing claims from 1 September 2023 to 30 April 2025; and semi-structured interviews with 20 general practitioners and four pharmacists from 13 June 2024 to 24 September 2024 to gauge their perspectives on 60-day dispensing. SETTING, PARTICIPANTS:General practitioners and pharmacists practising in New South Wales, Victoria and Queensland, Australia. MAIN OUTCOME MEASURE:Antihypertensive prescription volumes; patient and government cost savings; and perceptions of the policy from general practitioners and pharmacists. RESULTS:The 60-day antihypertensive prescription volume increased from 75,500 to 877,700 over 20 months, accounting for 21.2% of all antihypertensive dispensing by 30 April 2025. We estimate the total cost savings for patients were up to ~$65 million, and the government saved ~$87 million and paid pharmacies ~$86.7 million via the Additional Community Supply Support (ACSS) payment program, with a net effect of ~$0.3 million. In interviews, general practitioners indicated varied utilisation of 60-day prescriptions, with some actively providing 60-day prescriptions, but some rarely or not at all. Barriers included keeping abreast of eligible and ineligible medicines for 60-day prescriptions and perceived resistance from pharmacists. Pharmacists were concerned about incorrect dispensing and potential medication shortages. CONCLUSION:At 20 months after the introduction of the new policy, 21.2% of antihypertensive prescriptions were for 60-day dispensing. The slow uptake is likely due to low uptake among general practitioners and resistance from pharmacists. The 60-day policy has demonstrated substantial financial savings for patients. If uptake of 60-day dispensing increased to 50%, annual savings from antihypertensive medicines could rise to up to ~$165 million for patients and ~$11.6 million for the government.

Arm circumference determines appropriate blood pressure cuff size, which is critical for accurate measurements. This cross-sectional analysis aimed to assess cuff size needs according to mid-arm circumferences of Australian adults. Based on typical in-clinic cuff sizes, most Australians would require a medium (51.7 Appropriate blood pressure cuff size is critical for accurate measurements. Most Australians require a medium (51.7

BACKGROUND:Automated blood pressure (BP) devices may be less accurate in females than males, but this requires further investigation. This study aimed to determine sex differences in automated BP, measured with a single brand and model of device, compared with manual BP, with a focus on cuff sizes and associations with measures of adiposity. METHODS:Automated (Omron HEM-907XL) and manual BP were taken sequentially in a random order among a subsample of participants attending the US National Health and Nutrition Examination Survey, 2017 to 2018. Anthropometry and dual-energy x-ray absorptiometry were used to record body size and composition. Analyses, including multivariable regression to determine sex differences in BP, by cuff size, followed complex survey statistical principles. RESULTS:A total of 3735 participants (49.0% female [95% CI, 46.4-51.6], 45 years [43-46]) were included. In females, automated systolic BP (SBP) incrementally underestimated manual SBP across larger cuffs up to extra-large (-6.4 mm Hg [-8.0 to -4.9]). In males, automated SBP underestimated manual SBP only with extra-large cuffs (-2.4 mm Hg [95% CI-3.9 to -0.9]). Underestimation by automated SBP with extra-large cuffs was independently associated with all measures of body size indicative of increased adiposity in both females and males. Hypertension classification from automated and manual SBP had moderate agreement for adult/large cuffs (weighted kappa range 0.66-0.79) but weak agreement for extra-large cuffs (0.55-0.58) for females and males. CONCLUSIONS:The automated device used in this study underestimated manual SBP at larger cuff sizes, which was associated with indices of adiposity. Poorer accuracy of automated BP in larger cuff sizes could contribute to inequitable BP-related health care for females and males and requires further investigation.

Differences between automated cuff oscillometric blood pressure (BP) and invasive measurements are well described, but the causes are not fully understood. Automated BP devices record cuff oscillometric mean arterial pressure (MAP) as a key measurement step that is presumed to be accurate, but if not, could create error in cuff systolic (SBP) and diastolic BP (DBP) estimations. This has never been determined and was the aim of the study. Data from five studies with similar protocols were analysed (N = 262 patients undergoing coronary angiography, 61 ± 11 years, 65% male). Cuff oscillometric MAP was measured using five different models of automated cuff BP devices simultaneous to invasively measured MAP (fluid-filled or solid-state catheters). Cuff SBP and DBP were estimated by device-specific algorithms. Differences (∆) were calculated as cuff–invasive aortic BP. There were significant associations between ∆MAP and ∆SBP in four out of five devices (unstandardised β range = 0.42–1.04). The ∆MAP explained 6–52% of the variance in ∆SBP. In the same four devices, there were significant associations between ∆MAP and ∆DBP (unstandardised β range = 0.57–0.97) and ∆MAP explained 35–52% of the variance in ∆DBP. In conclusion, there are differences between cuff oscillometric MAP and invasive MAP which are associated with ∆SBP and ∆DBP. Further research is required to improve cuff oscillometric BP and greater transparency needed to understand algorithms used in these devices.

OBJECTIVE:Uscom BP+ is a cuff-based blood pressure (BP) device designed to noninvasively estimate central BP as distinct from conventional brachial BP. This study aimed to assess the accuracy of the Uscom BP+ device compared with invasively measured BP. METHODS:Automated noninvasive cuff central BP (using the Uscom BP+ device) and invasive central aortic BP were recorded simultaneously in 191 participants (65% male, aged 66 ± 11 years) receiving coronary angiography at three independent research sites in Australia, Poland, and Italy. Validation procedures were undertaken according to the Artery Society recommendations and with a minimally acceptable error (mean ± SD) of ≤5 ± ≤8 mmHg as pass criteria. RESULTS:Using the device default calibration technique [brachial cuff systolic blood pressure (SBP) and diastolic blood pressure (DBP)], cuff central SBP underestimated invasive central SBP [mean (SD) difference: -10.2 (11.2) mmHg] and cuff central DBP overestimated invasive central DBP [mean (SD) difference: 9.8 (8.5) mmHg]. When calibrating by brachial cuff mean arterial pressure and DBP, SBP accuracy was improved, but variability remained high [mean (SD) difference: -6.3 (14.4) mmHg, P  = 0.004 vs. default calibration, whereas DBP accuracy and variability remained similar [mean (SD) difference: 10.9 (8.5) mmHg, P  = 0.19 vs. default calibration]. CONCLUSION:The Uscom BP+ cuff device does not pass the Artery Society accuracy criteria compared with invasively measured central BP.

Background. Only 10-20% of blood pressure (BP) devices available are validated. Little is known about how and why patients choose BP devices for home BP measurement (HBPM), which was the aim of this study. Methods. Mixed-methods study (online survey (n=241), phone interviews among a purposive subsample (n=27)) among adults who perform HBPM in Australia (June-Dec 2023). Survey questions determined how BP devices were obtained, device make/model and factors influencing device selection. Interviews further explored these topics. Device validation status was determined using the STRIDE BP and Medaval websites. Results. Participants were middle aged (58+/-16 years, 52% women) and 91% purchased a device for HBPM (n=189; 9% borrowed a device), with 69% (n=130) purchased from pharmacies (53% validated) and 21% (n=39) purchased online (51% validated). Accuracy was said to be the most important consideration when choosing a device for most participants (n=129, 77%). Interview participants described using brand recognition, online reviews and cost to select an "accurate" device; avoiding cheaper devices and preferring brands used in healthcare settings. Participants did not consider validation status and did not receive advice on device accuracy at point-of-sale. Conclusion. This study highlights real world experiences of adults when obtaining HBPM devices that can be used to inform strategies to direct adults to validated devices. Strategies such as increasing signage at the point-of-sale and training healthcare practitioners to identify and direct consumers to validated devices may be effective in increasing uptake. Regulatory bodies should mandate the sale of validated devices in healthcare settings to increase availability. ### Competing Interest Statement Aletta E Schutte has received speaker fees from Omron, Medtronic, Aktiia, Servier, Sanofi, Novartis and is advisory board member for Skylabs and Abbott. ### Funding Statement Niamh Chapman is supported by a National Heart Foundation of Australia Postdoctoral Research Fellowship [2023-2024, #106657]. DSP is supported by a National Health and Medical Research Council Investigator Grant (GNT2018077) and is an Honorary Future Leader Fellow of the Heart Foundation of Australia (106618). Aletta E Schutte is supported by an NHMRC Investigator Leadership Grant [2023-2027, APP2017504). ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: This study was approved by the Human Research Ethics Committee of the University of Tasmania (H0028867) and informed consent was provided by all participants prior to participation. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes Data from this study are available upon reasonable request to the corresponding author.

Blood pressure monitoring is a critical aspect of prenatal care, as hypertension during pregnancy can lead to serious complications such as preeclampsia, eclampsia, and other hypertensive disorders. Automatic blood pressure devices are widely used for home monitoring due to their convenience and ease of use. The use of validated automated blood pressure monitors is recommended by the International Society of Hypertension for home blood pressure measurements, and automatic devices require accuracy validation among people who are pregnant before they are recommended for use in pregnancy. This study evaluated availability of such devices from 18 Australian pharmacies. Only four devices (4/54, 7%) were validated for pregnancy and were more expensive than devices validated for the general population (14/54, 26%) and non-validated devices (40/54, 74%). Additionally, limited labelling and information was available to assist consumers to make informed purchasing decisions about home blood pressure devices for use in pregnancy. Increased availability, clear labelling and consumer education could help ensure use of appropriate blood pressure devices in pregnancy. Automatic blood pressure devices require additional accuracy validation for use in pregnancy. We found only four devices (4/54, 7%) were validated for pregnancy, which were more expensive than non-validated devices. Increased education could help ensure use of appropriate blood pressure devices in pregnancy.

BACKGROUND:Systolic blood pressure (SBP) amplification is a physiological phenomenon related to the level of pressure difference between the aorta and brachial artery and is associated with cuff blood pressure (BP) measurement inaccuracy. However, knowledge on the invasively measured level of aortic-to-brachial SBP amplification is limited. This study aimed to explore this, as well as anticipated effects on hypertension classification. METHODS:A systematic review and individual participant data meta-analysis identified invasive brachial and aortic BP recorded in 1151 participants (62±12 years, 72% male). SBP amplification was calculated as brachial SBP minus aortic SBP. Hypertension classification (defined according to previously described thresholds for brachial and aortic BP) was compared between the aortic and brachial BP measures. RESULTS:There was a wide range of SBP amplification, which was similar between male and female (mean±SD, 8±9 mm Hg and 7±10 mm Hg, respectively) and decreased with increasing age. High SBP amplification (>15 mm Hg) was observed in 17.4% (male, 16.8% versus female, 19.5%; P=0.44), and low SBP amplification (<5 mm Hg) in 37.3% of participants (male, 37.2% versus female, 37.4%; P=0.95). The overall level of agreement between hypertension classification based on brachial and aortic BP was moderate (κ, 0.67; P<0.001; agreement, 87.4%). Agreement in hypertension classification was 65.0%, 38.1%, and 92.7% across classifications of optimal, prehypertension, and hypertension, respectively. CONCLUSIONS:In males and females there is wide variability in aortic-to-brachial SBP amplification. There were major theoretical differences in hypertension classification based on brachial versus aortic BP. This knowledge may help toward innovations for improving cuff BP measurement accuracy.

Background Adequate health literacy is integral to support self-management behaviours, including home blood pressure (BP) monitoring, which is recommended for hypertension management. Using a validated device that has been tested for accuracy is essential to obtain reliable BP readings, but only 25% of devices available for purchase at pharmacies meet this standard. Little is known about how consumers obtain BP devices, factors influencing their choices, and the impact of health literacy on device selection.Objective To determine how consumers obtain BP devices and explore the impact of health literacy on device ownership.Methods Mixed-methods study with an online survey and phone interviews among adults who measure BP at home in Australia (June-Dec 2023). Survey questions determined health literacy status, BP device make/model, validation status (evidence the device had been tested for accuracy) and factors influencing selection. Interviews further explored these topics among a subset of purposively sampled participants.Results Participants (n = 241) were middle aged (58 ± 16 years, 52% women) and 74% had adequate health literacy. Only 51% (n = 123) of participants used validated BP devices. Most participants purchased their device (91%, n = 189), with 69% (n = 130) from pharmacies. Regardless of health literacy level, accuracy, quality and recommendations from a medical professional were the most important considerations when selecting a BP device. More participants with inadequate health literacy considered medical professional recommendations as most important (48.8% vs. 29.1%, p = 0.035). However, no education was provided to support obtaining a validated BP device by healthcare providers. In the absence of education, interviewees (n = 27) used brand recognition, online reviews and avoided cheaper devices to select an ‘accurate’ device. Health literacy status did not impact ownership of a validated BP device or how devices were obtained.Conclusion Only 51% of Australian adults that measure BP at home use a device that has been tested for accuracy. Despite accuracy and medical professional recommendations being key considerations when choosing a device, little support was provided to aid participants to obtain a validated device. Our findings highlight the need for health services and providers to be more responsive to support consumers to obtain validated devices for home BP monitoring.

BACKGROUND:This study estimates the overall gaps between health system capacity of physician and nonphysician providers (nurses, pharmacists, and community health workers) and patients' needs for hypertension management across country income groups. METHODS:We extracted data on population, physician, and nonphysician density (nurses, pharmacists, community health workers) per 10 000 people from the World Bank Databases for 199 countries in 2021. Data on hypertension prevalence were obtained from the Non-Communicable Disease Risk Factor Collaboration (NCD-RisC) in 2021. We estimated patient need for clinic visits under 4 scenarios: 12 visits per patient per year (high demand [base scenario, reflecting common practice in many low- and middle-income countries, where physicians conduct monthly visits for medication refills]), 6 visits (intermediate scenario), 3 (low scenario), 1 (minimal scenario) and 2 scenarios based on health worker capacity to provide clinic services: 20 patients per day (base capacity) and 10 patients per day (low capacity) per provider. RESULTS:The overall prevalence of hypertension was 37.5 (SD, 6.6%): 36.2 (7.0%) in high-income countries, 40.3 (6.7) in upper middle-income countries, 36.1 (5.7%) in lower middle-income countries, and 36.7(4.8%) in low-income countries. Physicians (mean±SD, 19.2±17.4), nurses (47.3±54.1), pharmacists (3.9±4.7) per 10 000 were higher in high-income countries, whereas community health workers (3.4±7.3) were higher in low- and middle-income countries. All countries showed workforce deficits in the high-demand scenario, which eased under intermediate and minimal scenarios. Incorporating team-based care further reduced these deficits, yielding net surpluses in 36 countries. CONCLUSIONS:Our analysis highlights significant global health service capacity gaps if hypertension management continues to rely solely on physicians. Addressing these gaps requires expanding team-based care, improving training, and enhancing healthcare infrastructure.

BACKGROUND:Standardized automated office blood pressure (AOBP) measurement is widely accepted as the preferred method for monitoring blood pressure (BP) in health care settings. However, disagreements persist as to the need to perform AOBP unattended, where the patient is left alone in a quiet room. Thus, this study aimed to assess the BP differences between unattended and attended AOBP. METHODS:This systematic review and meta-analysis was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and registered on PROSPERO (International Prospective Register of Systematic Reviews). Studies were included if unattended and attended AOBP measurements were performed on the same participants in a randomized or alternating sequence order during a single visit, using the same device and measurement protocol. The primary outcome was the difference between unattended and attended systolic BP and the secondary outcome, the difference in diastolic BP. Pooled results were expressed as weighted mean differences (95% CI) obtained using random-effects meta-analysis. RESULTS:From 8088 screened studies, data were extracted from 15 studies (n=1747 participants). The unattended systolic BP and diastolic BP were -2.7 (-4.7 to -0.6) and -0.9 (-1.8 to -0.1) mm Hg lower than attended BPs. In a leave-one-out analysis, the overall difference was largely driven by a single outlier study. After excluding that study, the estimated difference was -2.0 mmHg (95% CI -4.1 to 0.0). CONCLUSIONS:Standardized unattended AOBP measurements result in slightly lower readings than attended AOBP. Whether these small measurement differences translate into clinically significant changes in management remains uncertain. Therefore, attended AOBP appears to be a reasonable option for BP measurement in a real-world clinical setting.

Conventional cuff-based blood pressure (BP) monitoring has several limitations, including patient discomfort with arm cuff inflation, inconvenience, and limited frequency of readings. Cuffless BP devices, which are increasingly available for purchase on the international market, have the potential to remove barriers to BP measurement in both research and clinical care. However, there are unanswered questions on whether, how, and in what settings these devices may be appropriate for use. Gaps include the need to understand whether the somewhat distinctive and often enormous volume of readings obtained by these devices have meaningful relationships with clinical outcomes and are appropriate for determining actionable interventions. Furthermore, international standards for determining the accuracy of some, but not yet all, of these devices only recently became available and do not provide a full assessment of the typical use of the devices. Thus, the devices on the market have not yet been adequately vetted for accuracy and efficacy. Several of these devices, however, have been cleared by the US Food and Drug Administration and are being used clinically. Moreover, many patients use cuffless devices for BP self-monitoring, often without disclosing this information to health care professionals. This scientific statement provides an overview of the existing literature on cuffless BP monitoring technologies and their potential future applications, and stresses the importance of understanding the gaps that need to be filled before these devices can be used clinically, recognizing that currently available devices may be inappropriate for clinical use.