Ambulatory Versus Home Blood Pressure Monitoring in Chinese Outpatients.

Out-of-office blood pressure measurement in children and adolescents

In 2008, the European Society of Hypertension (ESH) [1] and the American Heart Association/American Society of Hypertension [2] published guidelines for home blood pressure (HBP) monitoring and both recommended this method to be widely applied in clinical practice in both the initial diagnostic phase in patients with elevated blood pressure (BP) and also in the long-term follow-up of treated hypertension. These recommendations are based on the evidence about the prognostic value of HBP, its diagnostic ability, its cost-effectiveness, and its good acceptance by hypertensive patients [1,2]. Several studies have assessed the diagnostic value of HBP monitoring by taking ambulatory blood pressure (ABP) monitoring as reference method [1–4]. These studies, however, were quite heterogeneous with regard to their methodology and/or their objectives. First, 11 studies included untreated patients (n = 1866), whereas seven studies included treated hypertensive patients (n = 1059) [3,4]. Moreover, these previous studies included individuals on triple therapy, diabetic patients, patients with renal failure, on hemodialysis, or children and adolescents [3,4]. Second, the diagnostic endpoint was either white-coat hypertension, masked hypertension, sustained hypertension, white-coat effect, masked uncontrolled hypertension, resistant hypertension, or a mixture of these. Third, some studies have taken daytime ABP as reference whereas others focused on 24-h ABP as their reference, and different HBP schedules have been used [3,4]. The results of all these studies, although largely varying according to the diagnostic endpoint, tend to agree in indicating a higher specificity and higher negative predictive value with lower sensitivity and lower positive predictive value for the HBP monitoring method as compared with ABP monitoring. In this issue of the Journal of Hypertension, Kang et al.[5] provide further evidence in this regard, by reporting on the results of a cross-sectional study including data from 1774 patients in China, aimed at comparing the diagnostic accuracy of HBP with that of 24-h ABP monitoring. The results of this study are largely in line with the findings of the above-mentioned previous articles. Moreover, in these previous studies [3,4], there was moderate-to-substantial diagnostic agreement between the two methods (κ statistic 0.40–0.70) [6], a finding that is confirmed by the data by Kang et al.[5] who reported κ-statistic values 0.40–0.66 in untreated and 0.41–0.58 in treated patients when comparing the diagnostic agreement between HBP and ABP monitoring. Although rather confirmatory of previous papers, the study by Kang et al.[5] has several points of strength. First, analyses were performed on a large sample of individuals. Second, both treated and untreated individuals were included. Third, assessments of white-coat, masked and sustained hypertension were included in a single analysis. Fourth, 24 h rather than daytime ABP values were chosen to be taken as reference BP level, which means that night-time ABP was not ignored, in line with recent ESH ABP monitoring guidelines [7,8]. Indeed, the prevalence of masked hypertension was always significantly larger when this condition was assessed by 24-h ABP monitoring, regardless of the antihypertensive treatment status. Fifth, HBP monitoring was implemented according to the recommended schedule by ESH guidelines [1], with 7-day monitoring and duplicate morning and evening measurements. Sixth, assessment of HBP was based on readings exported by the device memory, which thus prevented misreporting; and seventh, implementation and conduction of this study was done in China where there are scarce data comparing HBP with ABP. Overall, the findings by Kang et al.[5] strengthen the importance of current recommendations indicating that presence of masked hypertension should be evaluated by taking into account a whole 24-h monitoring period and not only limiting the assessment to the awake period [7,8]. Somehow surprisingly, however, authors did not find an association between masked hypertension and advanced age, diabetes mellitus, and, more in general, major cardiovascular risk factors, a finding which is in contrast with other population studies [9–11]. Probably, this is related to the fact that cardiovascular risk level was only low to moderate in this study, and the mean age of the population was younger than in the previous articles. An additional explanation of such finding might be that Chinese hypertensive patients may behave differently from Caucasian individuals, and thus cross comparison of data collected in different ethnic groups worldwide could be useful to identify possible differences. The findings on the diagnostic agreement between HBP and ABP monitoring data in the study by Kang et al.[5] are supported by the results of a similar European study, which found a good agreement between HBP and ABP [12]. In fact, in this article, Nasothimiou et al.[12] also separately analyzed untreated and treated patients and focused on the assessment of white-coat, masked, and sustained hypertension, by investigating in a large dataset the diagnostic ability of HBP versus ABP [12]. Comparison of the two studies in Table 1 shows a striking similarity in the results with a high degree of diagnostic agreement between the two methods, ranging from 80 to 90% across all the hypertension phenotypes in both untreated and treated individuals.TABLE 1: Diagnostic agreement between home and ambulatory blood pressure monitoring in two studies that assessed all hypertension phenotypes separately in untreated and treated patientsThe occurrence of some degree of diagnostic disagreement between HBP and ABP is not an unexpected finding, and should be interpreted by taking into account a few important factors. First, the reproducibility of both HBP and ABP, although being clearly superior to that of office BP, is still imperfect, which means that some level of diagnostic disagreement would be expected even when the same BP monitoring method (HBP or ABP) is applied twice [13]. Thus, on such a background, the level of agreement between the two methods observed in the study by Kang et al.[5] as well as in the previous studies [3,4] might be regarded as excellent. Second, any diagnostic disagreement between HBP and ABP does not necessarily mean that ABP is the correct method and HBP is wrong. In fact, a level of disagreement should be expected because, although the two methods have important similarities (given that they both provide multiple measurements in the usual environment of each individual), they also have important differences. ABP is usually monitored only once, although over 24 h and in fully ambulatory conditions, at work, at home, and during sleep, whereas HBP is monitored over several days, weeks, or months, but always in the same environment and posture (seated after a few minutes of rest, at home). Third, because of the above-mentioned methodological differences, HBP and ABP monitoring appear to have a complementary rather than a competitive role in the evaluation of hypertension and provide similar but also different information about the BP profile and behavior. These data are supported by a study in 2051 patients assessed with HBP and ABP monitoring in Italy, which compared white-coat hypertensive patients who had normal HBP and ABP values with those who showed normal values only with one of these out-office BP monitoring methods, and showed that the latter group had higher risk of cardiovascular event and death [14]. An additional and important difference between data obtained in the study by Kang et al.[5] and data obtained in the previous studies is that in both untreated and treated patients of the study by Kang et al.[5], average diastolic HBP was at similar levels with average 24-h diastolic ABP, whereas systolic HBP was by 4–5 mmHg higher than 24-h systolic ABP. The study by Kang et al.[5] represents one of the first large studies assessing the respective diagnostic values of HBP versus ABP in the detection of white-coat and masked hypertension, in either untreated or treated hypertensive patients. This observational study, based on data collected in a large sample of Chinese hypertensive patients referring to hypertension clinics, yields several relevant new pieces of information on the features of white-coat and masked hypertension as assessed by these BP measuring methods. The low sensitivity and high specificity of home BP suggest that this technique may be useful to exclude a diagnosis of masked or white-coat hypertension but not to confirm its presence. This means that, in terms of hypertension management, ABP monitoring stands as the ideal tool to assess BP control, whereas HBP appears to be a complementary technique [1]. As a matter of fact, although ABP allows repeated measurements to be obtained both during awake activities and night sleep, this is not usually the case for HBP. On the contrary, at variance from 24-h ABP monitoring, self-BP measurements at home are collected over successive days, weeks, or months, which makes HBP monitoring a useful approach to BP assessment during long-term follow-up. With HBP monitoring, however, measurements are usually taken only during waking hours, without any possibility to have information also on night-time BP levels. Thus, on the background of the growing awareness on the importance of night-time BP, in the future, the power of HBP for detecting masked or white-coat hypertension should be tested by considering the inclusion of sleep readings. This possibility is currently provided by new devices for HBP monitoring that allow a number of night-time automated HBP measurements to be obtained. Use of these novel diagnostic tools may thus allow to more precisely check the predictive value of HBP vis-à-vis that of ABP, under more similar settings. In conclusion, the study by Kang et al.[5], together with the previous studies assessing the diagnostic ability of HBP monitoring, support the position of the ESH [1] that recommended the wide application of the method as a reliable alternative to ABP monitoring for the detection of the white-coat and masked hypertension phenomena and the confirmation of sustained hypertension both in the initial evaluation of untreated hypertension and also in the long-term follow-up, when assessing the occurrence of an effective BP control. ACKNOWLEDGEMENTS Conflicts of interest There are no conflicts of interest.

he conventional measurement of blood pressure(BP) in the office or clinic has been the cornerstonefor hypertension management for decades. How-ever, because of the white-coat and the masked hyper-tension phenomena, out-of-office BP monitoring withambulatory or home measurements is often required [1].ExtensiveresearchonambulatoryBPmonitoringhasestab-lished its role as the most accurate tool for hypertensiondiagnosis [1–3].Onthecontrary,despitetheincreasinguseof home BP monitoring by hypertensive patients in thedaily management of their high BP condition, research inthisfield,inparticularwhenconsideringoutcometrials,hasbeen delayed as compared to ambulatory BP monitoring[4,5].

We investigated accuracy of home blood pressure (BP) monitoring in the diagnosis of white-coat and masked hypertension in comparison with ambulatory BP monitoring. Our study participants were enrolled in the China Ambulatory and Home BP Registry, and underwent clinic, home, and 24-h ambulatory BP measurements. We defined white-coat hypertension as an elevated clinic SBP/DBP (≥140/90 mmHg) and a normal 24-h ambulatory (<130/80 mmHg) or home SBP/DBP (<135/85 mmHg), and masked hypertension as a normal clinic SBP/DBP (<140/90 mmHg) and an elevated 24-h ambulatory (≥130/80 mmHg) or home SBP/DBP (≥135/85 mmHg). In untreated patients (n = 573), the prevalence of white-coat hypertension (13.1 vs. 19.9%), masked hypertension (17.8 vs. 13.1%), and sustained hypertension (46.4 vs. 39.6%) significantly (P ≤ 0.02) differed between 24-h ambulatory and home BP monitoring. In treated patients (n = 1201), only the prevalence of masked hypertension differed significantly (18.7 vs. 14.5%; P = 0.005). Regardless of the treatment status, home compared with 24-h ambulatory BP had low sensitivity (range 47-74%), but high specificity (86-94%), and accordingly low positive (41-87%), but high negative predictive values (80-94%), and had moderate diagnostic agreement (82-85%) and Kappa statistic (0.41-0.66). In untreated and treated patients, age advancing was associated with a higher prevalence of white-coat hypertension and a lower prevalence of masked hypertension defined by 24-h ambulatory (P ≤ 0.03) but not home BP (P ≥ 0.10). Home BP monitoring has high specificity, but low sensitivity in the diagnosis of white-coat and masked hypertension, and may therefore behave as a complementary to, but not a replacement of, ambulatory BP monitoring.

sponsorship: The European Union (HEALTH-F7-305507 HOMAGE) and the European Research Council (Advanced Researcher Grant 2011-294713-EPLORE and Proof-of-Concept Grant 713601-uP-ROPHET) currently support research at the Studies Coordinating Centre in Leuven. (European Union|HEALTH-F7-305507 HOMAGE, European Research Council|2011-294713-EPLORE, European Research Council|713601-uP-ROPHET)

Ambulatory Blood Pressure Monitoring: Profiles in Chronic Kidney Disease Patients and Utility in Management.

Out-of-Office Blood Pressure Monitoring: A Comparison of Ambulatory Blood Pressure Monitoring and Home (Self) Monitoring Of Blood Pressure.

Can We Study Hypertension in Patients on Dialysis? Yes We Can

Objective: Out-of-office blood pressure (BP) monitoring using ambulatory BP (ABP) monitoring (ABPM) and home BP (HBP) monitoring (HBPM) is recommended for hypertension management. However, BP level measured by ABPM and HBPM may not be consistent even when evaluated the same time-window, morning. This study investigated the determinants of the difference between ABP and HBP in the morning time measured by a multisensor BP monitoring device equipped with a high-sensitivity actigraph and a thermometer. Design and method: Medicated hypertension patients enrolled in the Home-Activity ICT-based Japan Ambulatory Blood Pressure Monitoring Prospective (HI-JAMP) Study consecutively underwent office BP monitoring, 24-h ABPM (with 30-min intervals), and 5-day HBPM (twice each morning and evening) using the same multisensor BP monitoring device (TM-2441; A&amp;D Company, Tokyo). Morning ABP (average of 4 readings within 2-h after waking) and morning HBP (average of HBP readings measured in the morning over a HBPM period) were compared. In addition, this device recorded the wearer's fine-scale physical movement during a 24-h ABPM period and stored temperature data at the time of each BP measurement. Hourly averages of physical activity and temperatures at the time of HBPM (i.e., room temperature) were used for the analysis. Results: Among 2322 patients (males 53.2%, 69.2±11.5 years, average office systolic BP [SBP] 132.8±18.8 mmHg), morning home SBP was 2.4 mmHg higher than morning ambulatory SBP with standard deviation of 15.9 mmHg (ABP &lt; HBP). In a multivariable analysis including conventional risk factors, older age and larger number of antihypertensive agents were significantly associated with [HBP &gt; ABP], while history of cardiovascular disease (CVD) was significantly associated with [ABP &gt; HBP]. In the analysis additionally including physical activity in the morning and room temperature at the morning HBP measurement, higher activity level was significantly contributed to [ABP &gt; HBP] and lower room temperature was significantly contributed to [HBP &gt; ABP]. Conclusions: In treated hypertensive patients, HBPM is recommended especially if the patient is older, taking multiple antihypertensive agents, or living in an environment with lower room temperatures in the winter, while ABPM is recommended if the patient has a history of CVD.

> Two statisticians meet . > > -How do you do? > > -How do I do? Compared to whom? > > — Anonymous Thomas Pickering coined the term white-coat hypertension to denote individuals who were not on treatment for hypertension but who had elevated office blood pressure and normal daytime blood pressure measured with ambulatory blood pressure monitoring (ABPM). Clearly, these individuals would be at low cardiovascular risk.1 The traditional definition of white-coat hypertension is based, therefore, on an elevated office blood pressure with a normal blood pressure during the awake period with ABPM. However, because of the contribution of asleep blood pressure as a predictor of outcome, it seems counterproductive to exclude this period from consideration. The most recent European guidelines2 propose, therefore, an alternative definition of white-coat hypertension, which encompasses subjects with office systolic/diastolic blood pressure readings of ≥140/90 mm Hg and a 24-hour blood pressure <130/80 mm Hg. The purpose of this review is to provide new insights into the characteristics, definitions, and cardiovascular risk assessment in persons with white-coat hypertension, and it will be limited primarily to ABPM with a primary focus on prospective studies. ### Prevalence and Diagnosis White-coat hypertension occurs in 15% to 30% of subjects with an elevated office blood pressure,2,3 and the phenomenon is reasonably reproducible.2,4 Although there are no pathognomonic diagnostic features of white-coat hypertension, this condition occurs more frequently in women, older adults, nonsmokers, recently diagnosed patients with hypertension with a limited number of conventional blood pressure measurements in the office setting who have mild hypertension, pregnant women, and subjects without evidence of target organ damage.2,5,6 The misdiagnosis of subjects with white-coat hypertension as being truly hypertensive can result in them being penalized for employment and insurance rating, as well as being prescribed unnecessary lifelong treatment with potential side …

Objective: We investigated accuracy of home blood pressure (BP) monitoring in the diagnosis of white-coat and masked hypertension in comparison with ambulatory BP monitoring. Design and method: Our study subjects were enrolled in the ongoing China Ambulatory and Home Blood Pressure Registry and underwent clinic, home and 24-hour ambulatory blood pressure measurements. The blood pressure threshold for hypertension diagnostic was 140mmHg and/or 90mmHg (systolic/diastolic) for clinic blood pressure, 130mmHg and/or 80mmHg for 24-hour ambulatory blood pressure and 135mmHg and/or 85mmHg for home blood pressure. We defined white-coat hypertension as an elevated clinic systolic/diastolic pressure and a normal 24-hour ambulatory or home systolic/diastolic pressure and masked hypertension as a normal clinic systolic/diastolic pressure and an elevated 24-hour ambulatory or home systolic/diastolic pressure. Results: In untreated subjects (n = 573), the prevalence of white-coat hypertension (13.1% vs. 19.9%), masked hypertension (17.8% vs. 13.1%) and sustained hypertension (46.4% vs. 39.6%) significantly (P < 0.02) differed between 24-hour ambulatory and home BP monitoring. In treated subjects (n = 1201), only the prevalence of masked hypertension differed significantly (18.7% vs.14.5%, P = 0.005). Regardless of the treatment status, home compared with 24-hour ambulatory BP had low sensitivity (range, 47%-74%) but high specificity (86%-94%) and accordingly low positive (41%-87%) but high negative predictive values (80%-94%), and had moderate diagnostic agreement (82%-85%) and Kappa statistic (0.41–0.66). In untreated and treated subjects, age advancing was associated with a higher prevalence of white-coat hypertension and a lower prevalence of masked hypertension defined by 24-hour ambulatory (P < 0.04) but not home BP (P > 0.10). Conclusions: Home BP monitoring has high specificity but low sensitivity in the diagnosis of white-coat and masked hypertension, and may therefore behave as a complementary to, but not a replacement of, ambulatory BP monitoring.

Hypertension is a well recognized global public health issue and a major cause of cardiovascular events and death throughout the world [1–3]. It is responsible for about 13% of all deaths and 3.7% of total disability-adjusted life-years [1–3]. Globally, the overall prevalence of hypertension in adults was around 40% in 2008, and the number of adults with hypertension in 2025 has been projected to increase by about 60% to a total of 1.56 billion [1–5]. Hypertension is a chronic disease that requires periodic and correct measurements of blood pressure (BP) through three different but complementary alternatives: office BP, home BP, and 24-h ambulatory BP. Measurement of BP in the office is the cornerstone on which the knowledge of hypertension is based. Antihypertensive treatment targeted on office BP reduces the risk of cardiovascular disease, and the degree of benefit is associated with the magnitude of BP reduction [6–13]. However, office-based BP readings are limited in the amount of information they can provide as they represent a single snapshot in time [14–16]. Conversely, ambulatory BP monitoring (ABPM) provides a direct record of BP throughout the whole day in patients engaged in their usual activities. Frequent readings recorded at predefined intervals during wakefulness and sleep enable clinicians to obtain a more precise estimation of a patient's BP, to asses BP levels in the outpatient setting, and to study BP variability and circadian BP profile [15]. Furthermore, the evidence that ABPM provides information over and beyond conventional BP measurement has been growing steadily over the past 25 years, and the rationale for its use in clinical practice is soundly based [14,16–19]. Of note, clinical studies focused on the prognostic value of on-treatment ambulatory BP showed that ambulatory BP predicts cardiovascular events even after adjustment for classic risk factors including office measurements of BP [20–22]. In the office versus ambulatory blood pressure study, Clement et al.[21] assessed the association between ambulatory BP in treated patients and subsequent cardiovascular events with a median follow-up of 5 years. After adjustment for several confounders, including BP measured at the physician's office, higher mean values for 24-h ambulatory SBP and DBP were independent risk factors for new cardiovascular events. The adjusted relative risk (RR) of cardiovascular events associated with a 1-SD increment in BP was 1.34 [95% confidence interval (CI): 1.11–1.62] for 24-h ambulatory SBP, 1.30 (95% CI: 1.08–1.58) for ambulatory SBP during the daytime, and 1.27 (95% CI: 1.07–1.57) for ambulatory SBP during the night-time. For ambulatory DBP, the corresponding RRs of cardiovascular events associated with a 1-SD increment were 1.21 (95% CI: 1.01–1.46), 1.24 (95% CI: 1.03–1.49), and 1.18 (95% CI: 0.98–1.40). Similarly, in a prospective analysis of the Progetto Ipertensione Umbria Monitoraggio Ambulatoriale study [20], only 27% of treated hypertensive patients achieved office BP control (defined as BP < 140/90 mmHg), and 37% of patients achieved ambulatory BP control (defined as daytime BP < 135/85 mmHg). Ambulatory BP control significantly predicted a lesser risk for subsequent cardiovascular disease, whereas office BP control did not [20]. To date, ABPM appears to be an indispensable diagnostic tool in patients with established or suspected hypertension to refine cardiovascular risk stratification and guide therapeutic strategies. However, the use of ABPM for hypertension management may be more expensive than that of office or home BP. This aspect has been addressed by a recent comparative study estimating the resources consumed and subsequent costs for hypertension management, using home BP monitoring alone versus combined clinic measurements and ABPM (C/ABPM). Briefly, untreated hypertensive patients were randomized to use home BP or C/ABPM for antihypertensive treatment initiation and titration. The total cost of the first year of hypertension management was lower in home BP monitoring than C/ABPM arm (€1336.0 versus €1473.5 per patient, respectively), and there was no difference in achieved BP control and drug expenditure. The cost for subsequent years was €348.9 and €440.2 per patient, respectively, for home BP monitoring and C/ABPM arm and €2731.4 versus €3234.3 per patient, respectively (P < 0.001) for a 5-year projection. In view of the cost and limited availability of ABPM, increasing attention is being given to home monitoring with inexpensive semiautomated devices. In particular, this technique has attracted considerable attention in recent years because of the potential for better classification of hypertensive status and hypertension management compared with office BP [23,24]. A relationship between home BP values and the risk of cardiovascular disease has been documented in several observational studies [23,24]. These studies also have shown that the relationship with cardiovascular risk is steeper for home than for clinic BP [23,24]. On the contrary, there is no evidence from intervention studies that home BP is superior to office BP in guiding the treatment of hypertension. Hence, it remains uncertain whether tailoring treatment on the basis of home BP provides a better cardiovascular protection than traditional treatment based on office BP. To further investigate the hypothesis that on-treatment home BP monitoring provides information of prognostic significance, Shimada et al.[25] performed an additional analysis of the Home blood pressure measurement with Olmesartan Naive patients to Establish Standard Target blood pressure (HONEST) study. The report published in the current issue of the Journal [25] includes data from more than 20 000 hypertensive patients followed for about 2 years. Specifically, Shimada et al.[25] investigated the prognostic significance of office SBP and morning home SBP measured at several time points. Three types of BP measurements were evaluated: baseline BP, BP during follow-up (defined as the mean of all available BP measurements), and the achieved BP (defined as the BP measurement at the last time point during the follow-up period or the preceding day of the first cardiovascular event). Briefly, Shimada et al.[25] demonstrated that SBP during follow-up (as compared with SBP at baseline) and morning home SBP (as compared with clinic SBP) had a better prognostic significance in predicting cardiovascular events. When morning home and clinic SBP during follow-up were included in the same survival model, only morning home SBP during follow-up was identified as a significant predictive factor (hazard ratio per 1 mmHg increase: 1.033, 95% CI: 1.020–10.46, P < 0.0001) [25]. Despite the interesting results on the relation between home BP and outcomes in treated hypertensive patients, some methodological aspects of the analysis by Shimada et al.[25] need to be addressed for a proper interpretation of results. First, the percentage of patients who measured home BP according to current guidelines [26] ranged from 82.1% at baseline to 93.9% after 24 months, and the proportion of missing data on clinic BP measured at predefined time points is not reported. As pointed out by Agarwal [27] in a previous commentary on the HONEST study, if the missing data on clinic BP or home BP are not at random, they might selectively affect the association of home or clinic BP with outcomes. Second, when BP is taken at home to establish the diagnosis of hypertension or to assess BP control, the optimal schedule of BP measurements is still undefined. Increasing evidence suggests that at least 12–14 measurements should be obtained, with both morning and evening measurements taken over a period of 1 week. Yet in the HONEST study [25], home BP was only measured in two different days for each measurement point. Another aspect of the analysis by Shimada et al.[25] needs to be mentioned. To investigate the prognostic significance of clinic and home SBP, Shimada et al. developed several risk prediction models to estimate standardized hazard ratios (1 mmHg increase) and the 2-year absolute risk of cardiovascular events for each level of BP variable. To evaluate the model's discrimination ability and the clinical usefulness of added predictors, they also computed the concordance index and the net reclassification improvement (NRI), respectively. They computed NRI values when morning home SBP was added into the model including office SBP, and when clinic SBP was added into the model including morning home SBP. Interpretation of the results led the authors to conclude that follow-up morning home SBP had better reclassification ability [25]. The choice of a risk-category-based NRI seems reasonable in this context because it can demonstrate how many patients would be reallocated into different clinical risk categories by the addition of a specific BP variable. Unfortunately, Shimada et al.[25] did not report the components of the overall NRI to show the net percentages of patients with or without events correctly reclassified [28–30], and they reported overall NRI values well below 0.2, which should be considered weak and scarcely informative on a clinical standpoint. In conclusion, the use of on-treatment home BP, as recorded in the HONEST study [25], is difficult to translate into clinical decisions applied to drug treatment. However, the stage is set for a large, multinational, and intervention study formally testing the superiority of home versus office BP as a target for clinical decisions. According to current evidence, home BP monitoring provides complementary information to office and 24-h ambulatory BP [15]. It should be considered as a complementary, rather than a competitive, method to evaluate out-of-office BP [31,32]. ABPM remains mandatory to obtain information on components of the ambulatory BP profile which proved prognostic significance, including nocturnal BP dipping, ambulatory pulse pressure, night-time BP, and BP variability [16,33–38]. ACKNOWLEDGEMENTS Conflicts of interest There are no conflicts of interest.

Ambulatory blood pressure (ABP) monitoring is increasingly recognized as a valuable tool to refine prediction of cardiovascular risk related to blood pressure (BP).1 After the first landmark study published by Perloff and colleagues 24 years ago,2 several longitudinal event-based studies provided unequivocal evidence of an independent association between ABP and risk of cardiovascular disease. Although experimental procedures and statistical analyses varied from study to study, ABP generally improved cardiovascular risk stratification over and beyond traditional risk factors, including clinic BP.3 The Table, obtained through an electronic search of literature using the terms “ambulatory blood pressure” and “prognosis,” shows a list of longitudinal event-based studies performed by independent groups. It is worth noting that the list of available studies is longer because each group generally published other analyses of their database. Only the first-appearing or main contribution from each group has been included in the Table. View this table: Longitudinal Event-Based Studies From Independent Groups That Addressed the Prognostic Value of ABP Article p 2145 Three aspects of available investigations deserve special mention. First, the prognostic value of ABP has been examined not only in subjects with clinical diagnosis of hypertension but also in the general population and in a variety of settings, including diabetes mellitus, renal failure, and cerebrovascular disease. Second, subjects could be untreated or treated at the time of ABP monitoring. This point may raise concerns, because drug treatment could exert unpredictable effects on 24-hour ABP profile and, consequently, interpretation and applicability of results. Third, although a continuous relation emerged in most studies between ABP and cardiovascular risk, several investigators tried to define clinical categories based on arbitrary thresholds of ABP. Although such categories are potentially useful to make diagnostic and therapeutic decisions in clinical practice, their prognostic role requires confirmation from large and independent cohort …

Night-time blood pressure (BP) is strongly associated with hypertensive target organ damage; however, no previous studies have compared home BP monitor measurements of the reduction in night-time BP induced by antihypertensive medications with those obtained with ambulatory BP monitors. As part of the Japan Morning Surge-Target Organ Protection study, in which candesartan (thiazide diuretics were added, if needed) was administered to hypertensive patients in the morning or at bedtime, 50 hypertensive patients had their night-time home and ambulatory BP successfully measured at the baseline and 6 months. In addition, three night-time home BP readings were taken during sleeping hours (at 2, 3, and 4 o'clock) for 6 months. The mean reduction in night-time BP did not differ significantly between home and ambulatory BP monitoring (10.4 ± 17.9/6.0 ± 12.0 vs. 13.3 ± 14.6/7.6 ± 8.9 mmHg, P = 0.219/0.344), but the differences varied among individual patients. The reduction in night-time BP according to home BP monitoring was significantly correlated with the value obtained with ambulatory BP monitoring (r = 0.51/0.38, P < 0.001/=0.006). The reduction in night-time SBP according to home BP monitoring was significantly correlated with the reductions in left ventricular mass index (r = 0.385, P = 0.013, N = 41) and Sokolow-Lyon voltage (r = 0.335, P = 0.035, N = 40). Home BP monitoring produces estimates of mean night-time BP reductions comparable to those from ambulatory monitoring, while the differences varied among individual patients. The reduction in night-time home BP according to home BP monitoring is significantly correlated with the reduction in left ventricular hypertrophy.

Managing White‐Coat Effect