Lancet commission on hypertension group position statement on the global improvement of accuracy standards for devices that measure blood pressure The Lancet Commission on Hypertension identified that a key action to address the worldwide burden of high blood pressure (BP) was to improve the quality of BP measurements by using BP devices that have been validated for accuracy. Currently, there are over 3000 commercially available BP devices, but many do not have published data on accuracy testing according to established scientific standards. This problem is enabled through weak or absent regulations that allow clearance of devices for commercial use without formal validation. In addition, new BP technologies have emerged (e.g. cuffless sensors) for which there is no scientific consensus regarding BP measurement accuracy standards. Altogether, these issues contribute to the widespread availability of clinic and home BP devices with limited or uncertain accuracy, leading to inappropriate hypertension diagnosis, management and drug treatment on a global scale. The most significant problems relating to the accuracy of BP devices can be resolved by the regulatory requirement for mandatory independent validation of BP devices according to the universally-accepted International Organisation for Standardization Standard. This is a primary recommendation for which there is an urgent international need. Other key recommendations are development of validation standards specifically for new BP technologies and online lists of accurate devices that are accessible to consumers and health professionals. Recommendations are aligned with WHO policies on medical devices and universal healthcare. Adherence to recommendations would increase the global availability of accurate BP devices and result in better diagnosis and treatment of hypertension, thus decreasing the worldwide burden from high BP. Correspondence to James E. Sharman, Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia. Tel: +61 0 3 6226 4709; e-mail: james.sharman@utas.edu.au Received 7 June, 2019 Revised 5 August, 2019 Accepted 14 August, 2019 This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc-nd/4.0 Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Relationship between arterial stiffness and unattended or attended blood pressure values Background and method: Measurement of ‘unattended’ blood pressure (BP) may reduce or eliminate the ‘white-coat effect’. Despite the possible advantages of this approach for BP measurement, only few studies analysed the relationship between unattended BP and cardiovascular events or with hypertension-mediated organ damage (HMOD). The aim of our study was to evaluate the relationship between ‘attended’ or ‘unattended’ BP values and carotid-femoral pulse wave velocity (PWV) in 285 individuals undergoing a visit and assessment of arterial stiffness at an ESH Excellence Centre. Unattended BP (measured with the patient alone in the room, with an oscillometric device programmed to perform three BP measurements, at 1-min intervals, after 5 min) and attended BP were measured with the same device, on the same day of the measurement of PWV, in a random order. Results: Mean age was 63 ± 13 years, mean BMI 26 ± 4, 47% were women, 76% had hypertension (55% treated). Systolic unattended BP was lower than attended SBP (124.4 ± 14.3 vs. 130.9 ± 16.1 mmHg). PWV was similarly correlated with attended and unattended SBP values (r = 0.428 and r = 0.404, P < 0.0001, respectively). No difference for the prediction of increased arterial stiffness was observed at receiver operator curves (ROCs) analysis [attended SBP area under the curve (AUC) 0.665, 95% confidence interval (95% CI) 0.607–0.720 vs. unattended SBP: AUC 0.651, 95% CI 0.593–0.706, P for the comparison = ns]. Conclusion: Attended and unattended BP values are similarly correlated with PWV, the gold standard measure of arterial stiffness. These findings may provide further information on the clinical value of unattended BP. Correspondence to Massimo Salvetti, Department of Clinical and Experimental Sciences, University of Brescia & 2a Medicina ASST Spedali Civili di Brescia, Piazzale Spedali Civili n 1, Brescia 25123, Italy. Tel: +30 3995248; fax: +30 3388147; e-mail: massimo.salvetti@unibs.it Received 28 June, 2019 Revised 28 July, 2019 Accepted 1 August, 2019 Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Accuracy of fully automated oscillometric central aortic blood pressure measurement techniques Background: Central aortic blood pressure (cBP) is a valuable predictor of cardiovascular risk. The lack of fully automated measurement devices impeded an implementation in daily clinical practice so far. The present study compares two novel automated oscillometric devices with invasively measured cBP. Methods: From March 2017 to March 2018, we enrolled consecutive patients undergoing elective coronary angiography to this cross-sectional study. Noninvasive assessment of cBP was performed by the SphygmoCor XCEL device and the Mobil-O-Graph NG device simultaneously to invasive measurement. Results: Our study included 502 patients (228 women, 274 men) with a mean age of 67.9 ± 11.6 years. The noninvasive measurement of cBP was successful in 498 patients (99%) with SphygmoCor XCEL device and in 441 patients (88%) with Mobil-O-Graph NG device (P = 0.451). Measurements of both devices revealed a high correlation to invasively measured systolic (SphygmoCor R2 0.864, P < 0.001; Mobil-O-Graph R2 0.763, P < 0.001) and diastolic (SphygmoCor R2 0.772, P < 0.001; Mobil-O-Graph R2 0.618, P < 0.001) cBP. Both devices slightly underestimated systolic and overestimated diastolic central blood pressure: biases were −5.0 ± 7.7/0.5 ± 6.2 mmHg with SphygmoCor XCEL and −6.0 ± 10.4/3.6 ± 8.3 mmHg with Mobil-O-Graph NG device. Correlations (R2) were higher and biases were lower with the SphygmoCor device (P < 0.001 each). Conclusion: The present study is the largest validation study of noninvasive cBP measurement techniques so far and shows that two current automated oscillometric monitors are able to assess cBP with acceptable accuracy. Automated oscillometric devices may facilitate the implementation of cBP in daily clinical practice. Correspondence to Timm H. Westhoff, MD, University Hospital Marien Hospital Herne, Ruhr-University Bochum, Medical Department I, Hölkeskampring 40, 44625 Herne, Germany. Tel: +49 2323 499 1671; fax: +49 2323 499 3302; e-mail: timm.westhoff@elisabethgruppe.de Received 3 January, 2019 Revised 28 June, 2019 Accepted 8 August, 2019 Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (http://www.jhypertension.com). Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Vitamin D and blood pressure control among hypertensive adults: results from NHANES 2001–2014 Objective: Observational evidence supports an inverse association between hypovitaminosis D and blood pressure (BP), but intervention data have failed to demonstrate beneficial effects of vitamin D supplementation on BP. Following the downwards redefinition of hypertension treatment targets and the need to better identify individuals at greater risk for uncontrolled BP, our aim was to test the association of serum vitamin D levels with the definition of uncontrolled BP according to European guidelines in treated hypertensive adults. Methods: We retrospectively analyzed cross-sectional, nationally representative data from treated hypertensive adults aged at least 18 years with available serum 25 (OH)D measurements. BP was examined as continuous (mmHg) and categorical (at or above treatment goal, as recommended by guidelines) variable; BP means and odds ratios for uncontrolled BP according to vitamin D levels were calculated using progressively adjusted models. Results: Treated hypertensive adults with vitamin D deficiency had higher mean BP (+2.4/3.5 mmHg; P < 0.01) and 25–29% higher risk of uncontrolled BP compared to those with vitamin levels at least 75 nmol/l. These results were confirmed across age, sex, and racial/ethnic strata. Vitamin D insufficiency was associated with higher BP by 0.5/2.4 mmHg, but not with an increased risk of uncontrolled hypertension. Conclusions: 25 (OH)D levels might indicate host-specific features related to poor BP control. The attempt to use a biomarker of exposure as an indicator of need for treatment risks to be misleading. Correspondence to Rita Del Pinto, University of L’Aquila Department of Life, Health and Environmental Sciences, San Salvatore Hospital, Building Delta 6, L’Aquila, Italy. Tel: +39 0862 434752; e-mail: ritadelpinto@gmail.com Received 29 January, 2019 Revised 29 July, 2019 Accepted 1 August, 2019 Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (http://www.jhypertension.com). Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Short-term changes in dietary sodium intake influence sweat sodium concentration and muscle sodium content in healthy individuals Objective: There is increasing evidence that sodium can be stored in the skin and muscles without being osmotically active, yet whether acute changes in dietary sodium intake alter sweat and muscle sodium content has not been investigated previously. Methods: In a cross-over design, we assessed muscle sodium content by 23Na-MRI in 38 healthy normotensive volunteers (aged 33.5 ± 11.1 years, 76.3% women) after 5 days of high-sodium diet (6 g of salt added to their normal diet) and 5 days of a low-sodium diet. In a subgroup of 18 participants (72.2% women) we conducted quantitative pilocarpine iontophoretic sweat collections and measured the sodium concentration in sweat. Plasma aldosterone and plasma renin activity levels were measured in all participants. Results: Under high-sodium diet conditions urinary sodium excretion, muscle sodium content and sweat sodium concentration all increased significantly. Muscle sodium content (rm = 0.47, P = 0.03) and sodium sweat concentration (rm = 0.72, P < 0.001) correlated positively with salt intake as estimated by 24-h urine sodium excretion. Age, sex or the phase of the menstrual cycle did not influence muscle or sweat sodium concentrations or their changes. In contrast, plasma aldosterone levels were negatively associated with both muscle sodium (rs = −0.42, P = 0.0001) and sweat sodium content (rs = −0.52, P = 0.002). Plasma renin activity correlated negatively with sweat sodium (rs = −0.43, P = 0.012) and muscle sodium levels (rs = −0.42, P < 0.001). Conclusion: Muscle and sweat sodium concentrations are significantly higher on a high-salt intake in healthy male and female individuals, suggesting that muscle and sweat play a role in regulating sodium balance in humans. Correspondence to Philippe Braconnier, Service de Néphrologie, University Hospital of Lausanne, Rue du Bugnon 17, CH-1011 Lausanne, Switzerland. Tel: +41 213141154; fax: +41 21 314 11 39; e-mail: philippe.braconnier@chuv.ch Received 17 April, 2019 Accepted 2 August, 2019 Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (http://www.jhypertension.com). Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Augmented blood pressure variability following continuous infusion of noradrenaline in rats Objective: Augmented blood pressure (BP) variability has been shown to be associated with cardiovascular diseases. Activity of the sympathetic nervous system is an important determinant factor of the 24-h profile of BP variability, although it is unknown whether persistent adrenergic activation causes augmented BP variability or not. Here we report that continuous infusion of noradrenalin augments 24-h BP variability in rats. Methods: Nine-week-old male Wistar rats were continuously infused with subcutaneous 30 μg/h noradrenalin, 150 μg/h of the α1-adrenergic agonist phenylephrine, or 30 μg/h of the β-agonist isoproterenol, for 14 days. Noradrenalin-infused rats were also administered either oral 5 mg/day prazosin or 50 mg/day atenolol during the infusion period. BP variability was evaluated before and after 7 and 14 days of the infusion, using a coefficient of variation of BP recorded every 15 min under an unrestrained condition via an abdominal aortic catheter by a radiotelemetry system. Results: Continuous infusion of noradrenalin significantly increased 24-h BP variability at 7 and 14 days, slightly elevating BP levels, while this increase in BP variability was partially attenuated by prazosin, but not by atenolol. Continuous infusion of phenylephrine augmented BP variability, but isoproterenol had no effect on the variability. Conclusion: Continuous infusion of noradrenalin augmented 24-h BP variability partly through an α1-adrenergic receptor-mediated mechanism in rats, suggesting that the noradrenalin-infused rat is an animal model of augmented BP variability induced by persistent adrenergic activation. Correspondence to Danfeng Jiang, MMSc, Frontier Science Research Center, University of Miyazaki Faculty of Medicine, 5200 Kihara, Kiyotake, Miyazaki 889-1692, Japan. Tel: +81 985 85 9718; e-mail: danfen_jyan@med.miyazaki-u.ac.jp Received 19 May, 2019 Revised 17 July, 2019 Accepted 8 August, 2019 Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Associations of decision making abilities with blood pressure values in older adults Objectives: Decision making, key to successful aging, has implications for financial success, physical health, and well being. While poor decision making has been linked with increased risk of mortality, age-related cognitive decline, and dementia, less is known regarding its associations with chronic disease indicators. We investigated the associations of decision making with blood pressure (BP) values [i.e., SBP, mean arterial pressure (MAP), and pulse pressure (PP), separately] in a community-based cohort study of aging. Methods: Participants were 908 nondemented older adults (age ∼81 years; 75% women) from the Rush Memory and Aging Project. Decision making was measured using questions designed to simulate materials used in financial and healthcare settings in the real world and yielded a total score and domain-specific health and financial decision making scores. Two seated and one standing BP measurement were taken with all three contributing to average SBP, MAP that is, [SBP + (2 × DBP)]/3, and PP, that is, SBP − DBP. Participants were queried about hypertension status and antihypertension medications were visually inspected and coded. Participants also underwent medical history and cognitive assessments. Results: In separate multivariable linear regression models, total decision making scores were inversely associated with SBP, MAP, and PP after adjusting for age, sex, education, antihypertension medication use, diabetes, and cumulative cardiovascular disease burden (P values = 0.03). Decision making remained associated with these BP values after additional adjustment for global cognition. Conclusion: Poorer decision making is associated with higher BP values in nondemented older adults. Correspondence to Melissa Lamar, PhD, Associate Professor, Rush Alzheimer's Disease Center, Rush University Medical Center, 1750 W Harrison Street, Suite 1000, Chicago, IL 60612, USA. Tel: +1 312 942 3365; e-mail: melissa_lamar@rush.edu Received 6 June, 2019 Revised 19 July, 2019 Accepted 26 July, 2019 Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (http://www.jhypertension.com). Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

The association between 24-h blood pressure patterns and left ventricular mechanics Objective: We sought to investigate left ventricular (LV) mechanics in the recently diagnosed hypertensive patients with different 24-h blood pressure (BP) patterns (dipping, nondipping, extreme dipping and reverse dipping). Methods: The current cross-sectional study included 209 hypertensive patients who underwent 24-h ambulatory BP monitoring and comprehensive two-dimensional echocardiographic examination including multilayer strain analysis. Results: There was no difference in 24-h and daytime BP values between four groups. Night-time BP significantly and gradually increased from extreme dippers, across dippers and nondippers, to reverse dippers. LV global longitudinal and circumferential strains were greater in dippers and extreme dippers than in nondippers and reverse dippers. This was also found for endocardial and epicardial LV longitudinal and circumferential strains. Multivariate logistic regression analysis demonstrated that nondipping and reverse dipping patterns were associated with reduced LV longitudinal strain [odds ratio (OR) 1.71 (95% confidence interval (CI): 1.10–5.61) and OR 2.50 (95% CI: 1.31–6.82), respectively] independently of age, sex, 24-h SBP, LV mass index and E/è. Only the reverse dipping BP pattern was independently of clinical and echocardiographic parameters related with reduced LV circumferential strain [OR 1.90 (95% CI: 1.10–4.80)]. Conclusion: Nondipping and reverse dipping BP patterns had stronger impact on LV mechanics compared with patients with dipping and extreme dipping BP patterns in hypertensive population. LV functional and mechanical remodeling deteriorated from extreme dippers and dippers, to nondippers and reverse dippers. Correspondence to Marijana Tadic, Department of Internal Medicine and Cardiology, Charité–Universitätsmedizin Berlin, Campus Virchow-Klinikum, Augustenburgerplatz 1, 13353 Berlin, Germany. Tel: +49 17632360011; fax: +49 30450665111; e-mail: marijana_tadic@hotmail.com Received 4 July, 2019 Revised 29 July, 2019 Accepted 9 August, 2019 Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

The effects of repeated binge drinking on arterial stiffness and urinary norepinephrine levels in young adults Objectives: The aim of this study was to investigate the effect of repeated binge drinking and moderate alcohol consumption in young adults on arterial stiffness and sympathetic activity. Methods: We enrolled 49 healthy young adults, free of cardiovascular diseases (25 men; age: 23.5 ± 0.4 years; BMI: 23.4 ± 0.4 kg/m2; mean ± S.E). Individuals included were those with a history of repeated binge drinking (>2 years duration; n = 20), drank at moderate levels (MODs, >5 years duration; n = 16) and abstained from alcohol (last 2–3 years; n = 13). Arterial stiffness was assessed using carotid to femoral pulse wave velocity (cfPWV) and sympathetic activity was assessed using 24-h urinary norepinephrine levels. Also measured was aortic SBP and augmentation index (AIx), a measure of wave reflection. Results: Binge drinkers and MODs had higher cfPWV than alcohol abstainers (0.6 and 0.5 m/s, respectively; P ≤ 0.04). In addition, binge drinkers had higher urinary norepinephrine levels than MODs and alcohol abstainers (P < 0.05). Higher cfPWV were correlated with higher norepinephrine levels (r = 0.35. P = 0.02). Aortic SBP (P = 0.2) and AIx (P = 0.96) were similar among binge drinkers, MODs and alcohol abstainers. Conclusion: Our findings suggest that repeated exposure to alcohol, regardless of drinking pattern, may increase aortic arterial stiffness in healthy young adults. In addition, sympathetic activation, reflected by increased 24-h urinary norepinephrine levels, may contribute to alcohol-induced arterial stiffening in young adults. Correspondence to Shane A. Phillips, PT, PhD, FAHA, 1919 W. Taylor St. MC898, Chicago, IL 60612, USA. Tel: +1 312 355 0277; fax: +1 312 996 4583; e-mail: shanep@uic.edu Received 11 July, 2019 Revised 27 July, 2019 Accepted 29 July, 2019 Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Inhibition of the renin-angiotensin system in the cardiorenal syndrome with anaemia: a double-edged sword The term ‘cardiorenal syndrome’ (CRS) was introduced to describe problems related to the simultaneous existence of heart and renal insufficiency. The prevalence of anaemia in CRS is high and increases the risk of hospitalizations and death. Renin-angiotensin system (RAS) inhibition is the cornerstone therapy in cardiovascular and renal medicine. As angiotensin II regulates both glomerular filtration rate (GFR) and erythropoiesis, RAS inhibition can further deteriorate renal function and lower hematocrit or cause anaemia in patients with heart failure. The aim of this review is to explore the relationship among CRS, anemia and administration of angiotensin-converting enzyme inhibitor (ACEi) or angiotensin receptor blocker (ARB) and summarize the evidence suggesting that RAS inhibition may be considered an iatrogenic cause of deterioration of CRS with anemia. It should be emphasized however, that RAS inhibition reduces mortality in both groups with and without worsening of renal function, and therefore, no patient with CRS should be denied an ACEi or ARB trial without careful evaluation. Correspondence to Demetrios V. Vlahakos, Renal Unit, Attikon University Hospital, 1 Rimini Street, Haidari, Athens 12462, Greece. Tel: +30 210 583 2346; fax: +30 210 6747480; e-mail: vlahakos@otenet.gr Received 17 May, 2018 Revised 12 January, 2019 Accepted 11 March, 2019 Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.