Optimal Blood Pressure we Should Target? Systolic Under 110 or 100?

#204

This is the only source I’ve found that reviewed both devices (and it’s a blog…):

The reviewer seems subjectively to prefer the Aktiia.

The Omron was released in Jan 2019. If it worked well I assume everyone in this forum would already wear one. Peter Attia, Eric Topol and Adam Bataineh also used to say that cuffless devices didn’t work. But after trying Aktiia they said that we might have the first functioning cuffless continuous BP monitor.

So I’d bet on Aktiia. But that’s also probably that they’re better at marketing. Time will tell…

#205

Well I was in hospital recently for a planned surgery, spent three days there and my blood pressure was measured every two to three hours with hospital equipment and I was wearing Aktiia bracelet all the time and I must say that I was pleasantly surprised measurements did align.
I am wearing Aktiia now for three months and I see that my BP is quite OK, stable and low, now with halved sodium intake it averages 106/65 over 24h. I believe it is time to retire Aktiia and pass it on to my mother in law. I will probably do a similar 3 months in depth look into my BP in few years hoping that by then things will be much clearer about reliability and precision of optical BP sensors and hopefully integrated in one multi function device like Apple watch or Whoop.

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#206

Yes, I think form factor and no hassle with Aktia means it will win. My question though, was/is: which one you think is more accurate?

We’ve seen from @John_Hemming that there can be big accuracy issues with Aktia

Still I will likely buy one once its available in the US

The question I’m facing now is whether to just wait for that (could be a year, even years perhaps…), or consider getting the Omron wearable now.

My hypothesis is that they will complement each other with (1) Aktia being easier/less invasive and better for getting night time data without impacting sleep while (2) Omrom would be better for morning and then through days measurements from an accuracy perspective.

So I was trying to stress test part (2) as that is where I’m less confident (thing (1) is very high confident read)

#207

Ok sorry I didn’t get it because… I thought Omron was more or less identical to Aktiia. I’ve just checked the photos and now I understand your question. Anyway, same feedback: based on what I read I feel like Aktiia might be more accurate. But that’s just a feeling.

Maybe message Aktiia’s CMO on LinkedIn and ask him about a rough time-line for FDA approval. He answered my message (complaining about their poor customer service :joy:) in less than 24h: Jay Shah - Aktiia | LinkedIn

If he confirms approval is for 2024, I’d wait for Aktiia. If not, Omron. (You can also import the Aktiia and make it work in the US, but I’d avoid that as you one day they’ll lock your device based on geo location, CGM manufacturers do that and it’s so annoying.)

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#208

From Dec 2023: Performance of wearable watch-type home blood pressure measurement devices in a real-world clinical sample

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While we could not formally validate the cuffless devices, our results show that wearable technologies will require improvements to offer reliable BP assessment. This study also highlights the need for validation protocols specifically designed for cuffless BP measurement technologies.

Too bad they didn’t test Aktiia as well… There are other recent papers about Aktiia showing that it performs well but all of them are funded and/or co-authored by Aktiia so I won’t post them.

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#209

First impressions after 48 hours of using the Aktiia device:

  • Great user experience. Feels more like consumer tech than a medical device in terms of product unboxing, device design, and app UX. It’s not as good as Apple, but it’s 10x better than Abbott or Dexcom, for instance.
  • A traditional cuff is included for the calibration (to do once in a month). It can be used independently from the Aktiia device, you can put the cuff on, open the app and press “Take Cuff measurement”. So you have a normal approved cuff BP monitor with results instantly sent to your smartphone that you can plot nicely, share with your doctor, etc. A bit like Withings BPM Connect (~$100). So just that might justify the purchase of the Aktiia (~$200).
  • It measures your BP at random times (on average every 30 min) whenever you don’t move too much. You cannot take a “cuffless” measurement whenever you want. So it makes the comparison with an independent cuff device less easy. I would have to sit with my traditional device, wait, periodically refresh the app to see whether the Aktiia device took a measurement and then at the point do a traditional measurement (on the same arm? on the other arm?). Or just measure the traditional way and then take the closest Aktiia figure. Or the average of the one before and after, but they might be 1h before! That difficulty was mentioned in one paper I read comparing Aktiia to a 24h ABPM (they also try to do it randomly every 30 min or so, but sometimes it fails, and of course they don’t have the exact same times as the Aktiia ones, so you can compare the mean/min/max values, the shape of the curve and the area under the curve but you cannot really do point to point comparisons)
  • The app only displays time in range and thresholds based on the European 135/85 target. Contrary to CGMs you cannot change the target to have your own personalized one. The choice of 135/85 is weird because the European guidelines actually give 135/85 awake and 120/70 asleep. The app asks you when you go to sleep and when you wake up so they should be able to display two targets. Of course, the “optimal” US targets are lower: 120/80 daytime and 100/65 nighttime.

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  • One of the rare fully independent studies of the Aktiia device showed that it was accurate during the day but overestimated SBP by +15.5 mm Hg and DBP by +11.8 during the night: Angiotensin II receptor blocker (ARB) experiences? - #14 by adssx Aktiia criticized this paper in subsequent papers of their own (where they of course showed that Aktiia was also super accurate overnight). And yet, compared to my traditional 24h ABPM from Dec 2022, my Aktiia results from yesterday are almost identical during daytime but over-estimated during nighttime (SBP +11 mmHg and DBP +12 mm Hg). Good to know… (incorrect reasoning: see below)
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#210

Very helpful.

Re

What is night time ABPM - how do you get it to compare vs Akita?

#211

Good question, I’ve just checked by two previous 24h ABPM. In 2015 they used 22:00–8:00 to define “night”. In Dec 2022 they used 1am–6am to define “night”… Nonsense… So actually my “daytime” and “nighttime” average figures from Dec 2022 don’t make any sense as I probably went to sleep around 10–11pm and not 1am…

For Aktiia, they ask you when you go to sleep and when you wake up in general (you can then change it for a specific exceptional day) and that how they define “daytime” and “nighttime”.

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#212

I think it is good to compare to manual measurements over time. I got some Aktiia measurements that are really unusual for myself, but further review of hours when Aktiia measurements were taken showed that measurements were during or just after a brisk bike ride or similar. I also did few tests were I took measurements with cuff and Aktiia sensor at approximately same time (yes I waited in dark room for the green sensor light). All my measurements are within really small margin of error. It is good to test Aktiia cuff as well as this is the key for calibration and calculation from optical sensor. I noticed after my second calibration (after 1 month) that I had raised BP (+5 points) over few days, but after three days it became clear that something might be wrong with my calibration measurement as my BP followed the same pattern as before it was just 5 points higher. I recalibrated (was careful with positioning my cuff) and measured with my manual machine at the same time to confirm Aktiaa cuff measurement and my BP was back to my usual numbers. Probably I positioned cuff carelessly or was moving too much…
My Aktiia results after using it for 2 months is more or less same than 24h ABPM I took some months before. This last month I have reduced the sodium to around 2500mg daily, daily banana and few gram of L-Citruline with my morning smoothie and I see my BP has reduced significantly (-8 points).

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#213

Good to know, thanks.

By the way, I have the “NEW Aktiia” that is supposed to be waterproof, “70% easier to initialise” (what does that even mean?!), “31% lighter”, and with “a 7.5% increase in daytime data density”. However, it seems that you can only buy that new device on this special hidden Christmas page. The normal page still shows “Not Water Resistant” and “Weight 20g”. Great product but terrible communication…

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#214

I used Citrulline for a while and when I first started with it, I saw a similarly dramatic drop in blood pressure too what you report.

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#215

I ordered the “NEw Akttia” and had it delivered to a friend in the UK. Looking forward to playing with it when it arrives in Canada. Thanks for the background info @adssx!

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#216

You might have to set up your phone in the UK on the Play Store and/or to install some kind of special app to use it.

#217

Ya, I’ve done it before with other apps. But that was long ago, so I’ll need to refresh my memory. Rapadmin has posted a thread about to go about it.

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#218

Yes - in this post: Has Anyone Seen a Rise in Blood Pressure Using Rapamycin? - #239 by RapAdmin

#219

Hi @Tomnook: which interventions did you do (if any) to go from 169/96 to 117/72?

Also, on these reports, I find it so annoying that they use different definitions of hypertension. On the “Monthly graph view - BP”, the red lines show 130/80, which is the European threshold for hypertension based on 24h ABPM. It makes sense as Aktiia is a 24h ABPM. However, in the “Percentages in range”, the color map uses the office limits (still from the European guidelines), so 140/90 at the limit for hypertension. It’s not their fault, as the European guidelines only give the detailed classification of hypertension for office BP measurements. (And to make things worse, on the home page of the app, they use the 135/85 cutoff, which is for home measurements) It doesn’t change the value but it makes the interpretation less easy. For instance, I appear in “High blood pressure stage 1” in the monthly graph but “Elevated” (aka normal) in the color map.

Anyway, I’ve just started telmisartan 20 mg. I guess it’ll take a few weeks to see the effects.

By the way, telmisartan seems the best choice by far (see: Angiotensin II receptor blocker (ARB) experiences? - #25 by adssx ), but it looks like increasing the dose doesn’t have much impact after 40 mg:

Following once daily administration of telmisartan, the magnitude of blood pressure reduction from baseline after placebo subtraction was approximately (SBP/DBP) 6-8/6 mmHg for 20 mg, 9-13/6-8 mmHg for 40 mg, and 12-13/7-8 mmHg for 80 mg. Larger doses (up to 160 mg) did not appear to cause a further decrease in blood pressure. (https://www.accessdata.fda.gov/drugsatfda_docs/label/2009/020850s022s023lbl.pdf)

Angiotensin II receptor antagonist telmisartan in isolated systolic hypertension (ARAMIS) study: efficacy and safety of telmisartan 20, 40 or 80 mg versus hydrochlorothiazide 12.5 mg or placebo 2018

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It looks like all ARBs have this property: Antihypertensive efficacy of angiotensin receptor blockers as monotherapy as evaluated by ambulatory blood pressure monitoring: a meta-analysis 2013

Overall, the dose–response curve with ARBs was shallow with decrease of 10.3/6.7 (systolic/diastolic), 11.7/7.6, and 13.0/8.3 mmHg with 25% max dose, 50% max dose, and with the max dose of ARBs, respectively. […] we observed a shallow dose–response curve, and uptitration marginally enhanced the antihypertensive efficacy.

So, what would be the second-best antihypertensive after telmisartan? So far I’d say dihydropyridine CCBs such as amlodipine but there’s not much data. Amlodipine seems to have good synergy with telmisartan (and telmisartan/amlodipine is on the WHO List of Essential Medicines):

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Clinical utility of fixed-combination telmisartan–amlodipine in the treatment of hypertension 2011

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#220

Hi!
I’m still doing pretty much the same as I was when asked earlier in this thread. I now use the ‘new’ Aktiia (seems virtually identical to the previous version although I must say the bracelet connects more easily for readings). My BP has risen slightly over the past month 119/74 average up from 114/73 - maybe I wasn’t as relaxed when I ran this month’s calibration.
Two years ago when I was admitted to hospital my BP at the doctor’s was 220/100 - it fell to 200/100 at admission and after two or three days it was down to 180/90 - they started me on ramipril 2.5mg od and amlodipine ccb 10mg od. There was little change so the ramipril was upped to 10mg od. After four days I was discharged after showing the consultant my Akttia readings when I was relaxed in the hospital bed compared to the hospital readings when they wheeled their infernal machine over to me - the readings were never under 180 (which I needed them to be for discharge).
The consultant suggested reducing salt in my diet (vegetarian but ‘ready meal’ type of food - high salt content) whilst also stopping eating liquorice (which I’d not previously realised the effect of).
A week or so post discharge I stopped the ccb due to a noticeable increase in pulse rate and an apparrent decline in hrv.
Over the following months I reduced the ramipril to 2.5mg od (before bed) and remain at this dose.
I started a number of supplements all of which I still take on a regular basis and many of which I took on and off over the fifteen years prior to this event. The only ones which I’m fairly certain have some effect are arginine and l-citrulline and beetroot powder. Here are all of them:
Arginine 2g am
Citrulline 2g pre bed
Beetroot 1g 20:1 extract
Hawthorn powder (fruit and leaves)1.5g 20:1 extract
Krill oil 1g
EPA/DHA 1g
Astaxanthin 12mg
Pine Bark extract 400mg 15:1
I also practice mindfulness a couple of times a day for 1 minute and also for 5 minutes before sleep.
Increased daily water intake significantly.

I’m retired and, as far as possible, consciously avoid situations which I know would raise my BP - realively easier to do these days.

Your comments about telmisartan are interesting and the studies I’ve just looked at make it the obvious choice as the ARB to try. I asked my GP if he’d prescribe me an ARB originally but he wanted to try ramipril first so I’ve stuck with that. There is synergy in taking low doses of both ramipril and telmisartan in some studies it appears.

Amlodipine appears to be the most commonly prescribed ccb and combined with the telmisartan looks like a good combination.

I understand your comments about the Aktiia kit - I hadn’t thought about them before - I was just keen to get my levels into the green zone and then, once there, keep them in it!

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#221

When I got 24h ABPM device I got some patient information that states in short that normal BP is considered 24h average lower than 115/75 mmHg. If BP is greater than 125/75 (again 24h average) you are probably hypertensive and BP will be further evaluated.

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#222

Thanks a lot for sharing your protocol @Tomnook.

Yes, my conclusion so far is that the best strategy to achieve the desired target is: Telmisartan 20 mg => T 40 mg => T 40 mg + Amlodipine 2.5 mg => T 40 mg + A 5 mg => T 40 mg + A 5 mg + Hydrochlorothiazide (HCTZ) 12.5 mg

It might be better to start with the low-dose combination, but it’s not available. One manufacturer is actually developing something similar (with the thiazide-like indapamide instead of HCTZ, not sure it’s better though): Rationale for a New Low-Dose Triple Single Pill Combination for the Treatment of Hypertension 2024

In both trials, these ‘hypertension polypills’ were superior to usual care, achieving >80% BP control without increasing withdrawal due to side effects. However, there are no such products available for prescribers. To address this unmet need, George Medicines developed GMRx2 with telmisartan/amlodipine/indapamide in three strengths (mg): 10/1.25/0.625, 20/2.5/1.25; 40/5/2.5.
The systolic BP (SBP)-lowering efficacy of GMRx2 strengths 1, 2 and 3 (Table 2) from a baseline SBP of 150 mmHg are expected to be approximately 13 mmHg, 18 mmHg and 25 mmHg, respectively. This represents a much greater and clinically important BP reduction in comparison to standard-dose monotherapy, which reduces SBP compared with placebo by only 8–9 mmHg on average, with each doubling of dose conferring only a 1–2 mmHg incremental SBP reduction

They completed the trials. I can’t wait to see the results.

[Update: actually, indapamide might be better than HCTZ as it has a longer half-life and might cause less insulin resistance. Telmisartan is the longest-acting ARB and amlodipine is the longest-acting CCB and long-acting drugs are preferred to reduce BPV per this source. So Telmisartan/Amlodipine/Indapamide might be the best combo out there.]

I agree that 115/75 mm Hg should be the ideal BP (if not lower). Unfortunately, the 2023 European guidelines still give 130/80 as the 24h ABPM threshold for hypertension while the American guidelines have been lowered to 125/80 since 2017:

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I did a 24-hour ABPM in 2015 in France (130/69) and in 2022 in the UK (132/73), and in both cases the cardiologists concluded that I was “normotensive”. (To their defense, “Isolated systolic hypertension of the young” [ISHY] is apparently common and not associated with an increased risk for non-smoking and physically active tall men.) I tried to argue a bit (it seemed stupid to me to have an arbitrary threshold set in stone versus seeing things as a continuum) but I didn’t know much back then (and I had other things to focus on…).

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Angiotensin II receptor blocker (ARB) experiences?
Lithium Supplementation
#223

I thought this might help you make your decision: Aktiia has 4 ongoing trials. Omron: none? So, at least Aktiia seems quite confident about its product and serious about proving its accuracy. And we might get the results of the first trial by the end of this year:

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