Community Practices and Perceptions Regarding Blood Pressure Measurement Techniques.

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

The aim of the present study was to evaluate the agreement, mean difference, prevalence, and control rates of arterial hypertension between clinic (i.e. office) and home blood pressure (BP) measurements in a general population. Variations in home BP between morning and evening measurements and the dynamic changes during 7 days of measurements were also examined. A total of 200 participants were selected from three communities in the Beijing area. Patients underwent a clinical interview and measurement of both clinic and home BP. Thresholds for elevated clinic and home BP were defined as at least 140/90 and 135/85 mmHg. Systolic and diastolic BP measured at clinic was higher than at home; the mean difference was 3.1/1.6 mmHg in all participants and 6.2/1.1 mmHg in hypertensive patients. With home BP monitoring, the first day of monitoring showed the highest and most varied (as reflected by standard deviation) BP readings. Home diastolic BP was significantly higher in the morning (76.6 ± 10.1 mmHg) than in the evening (74.2 ± 9.8 mmHg, P<0.0001), but home systolic BP was not. The prevalence of hypertension was higher when estimated by clinic versus by home BP (53.0 vs. 39.6%, P=0.025); and the control rate of hypertension tended to be lower when estimated by clinic versus by home BP (56.1 vs. 64.1%, P=0.24). The overall agreement between clinic and home BP in diagnosis of hypertension was 80.3% (κ coefficient: 0.6). The present study in 200 Chinese demonstrates that BP is higher (a) at the clinic setting compared with at home and (b) on the first day of initiating home BP monitoring. There is moderate agreement between clinic and home BP in diagnosing hypertension. As home BP measurements may best represent the 'true' BP level in normotensives and hypertensives, its use in clinical practice should be promoted.

The purpose of this study was to assess the agreement, mean difference, and the detection and control rates of hypertension, between home and clinic blood pressure (BP) measurement in the Finnish population. Variation in home BP during the measurements was also examined. We studied a representative sample of the adult population (2051 45-74-year-old individuals) in Finland. Subjects included in the study underwent a clinical interview and measurement of clinic and home BP. Thresholds for elevated clinic and home BP were 140/90 and 135/85 mmHg. The mean difference between home and clinic BP, which increased with BP, was 7.7/3.4 mmHg. Overall agreement in diagnosis was only 75.2% (kappa coefficient 0.50). As compared with home BP, clinic BP overestimated the prevalence of hypertension (48.8 versus 42.5%, P < 0.001) and non-significantly underestimated the control of hypertension (28.7 versus 32.8%, P = 0.11). Evening home BP was 4.1/0.4 mmHg higher than morning BP among untreated subjects, but this difference was non-existent or reversed (0.5/-1.4 mmHg) among treated hypertensive individuals. Home BP decreased with an increasing number of measurements. The agreement between home and clinic BP in diagnosing hypertension according to the current guidelines is moderate at best, and the difference between home and clinic BP becomes larger at higher levels of BP. Because of the noticeable differences between these two methods, and the better prognostic accuracy of home BP, we endorse the use of home measurements in clinical practice.

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

Controlling hypertension has been revealed to be as important as controlling hyperglycemia to prevent the progression of diabetic nephropathy. Home blood pressure (HBP) measurement is useful for the treatment of hypertension. This study aimed to determine whether HBP measurement is a stronger predictor of the progression of diabetic nephropathy than clinic blood pressure (CBP) measurement. A multicenter follow-up study was performed at the Japan National Hospital Organization. A database of type 2 diabetic patients was constructed. In addition to CBP measurement patients, those using HBP were included in the database. Fifty-four patients with diabetic nephropathy were extracted from the database and analyzed. The rate of decline of the estimated glomerular filtration rate (eGFR) was calculated as the outcome. Correlations between the rate of eGFR decline and various clinical and laboratory parameters, including HBP and CBP measurement, were analyzed. The white-coat effect and reverse white-coat effect were frequently observed. The rate of eGFR decline correlated significantly with home systolic blood pressure (HSBP) measurement, but not with clinic systolic blood pressure (CSBP) measurement. Stepwise multiple linear regression analysis was performed. The rate of eGFR decline was significantly explained by the morning HSBP reading. The rate of eGFR decline was also significantly explained by the average of the morning HSBP readings during the follow-up period, the eGFR and age at baseline in the model, which included CBP and HBP measurements during the follow-up period instead of those at baseline. Home blood pressure measurement is useful for predicting the prognosis of diabetic nephropathy.

To compare multiple clinic and home blood pressure (BP) measurements and ambulatory BP monitoring in the clinical evaluation of hypertension, we studied 239 middle-aged pharmacologically untreated hypertensive men and women who were referred to the study from the primary healthcare provider. Ambulatory BP monitoring was successfully completed for 233 patients. Clinic BP was measured by a trained nurse with a mercury sphygmomanometer and averaged over 4 duplicate measures. Self-recorded home BP was measured with a semiautomatic oscillometric device twice every morning and twice every evening on 7 consecutive days. Ambulatory BP was recorded with an auscultatory device. Two-dimensionally controlled M-mode echocardiography was successfully performed on 232 patients. Twenty-four-hour urinary albumin was determined by nephelometry. Clinic BP was 144.5+/-12.6/94.5+/-7.4 mm Hg, home BP (the mean of 14 self-recorded measures) was 138.9+/-13.1/92.9+/-8.6 mm Hg, home morning BP (the mean of the first 4 duplicate morning measures) was 137.1+/-13.7/92.4+/-9.2 mm Hg, daytime ambulatory BP was 148.3+/-13. 9/91.9+/-7.8 mm Hg, nighttime ambulatory BP was 125.5+/-16.4/75. 6+/-8.9 mm Hg, and 24-hour ambulatory BP was 141.7+/-14.0/87.2+/-7.6 mm Hg. Pearson correlation coefficients of clinic, home, home morning, and daytime ambulatory BPs to albuminuria and to the characteristics of the left ventricle were nearly equal. In multivariate regression analyses, 36% (P<0.0001) of the cross-sectional variation in left ventricular mass index was attributed to gender and home morning systolic BP in models that originally included age, gender, and clinic, self-measured home morning, and ambulatory daytime, nighttime, and 24-hour systolic and diastolic BPs. We concluded that carefully controlled nonphysician-measured clinic and self-measured home BPs, when averaged over 4 duplicate measurements, are as reliable as ambulatory BP monitoring in the clinical evaluation of untreated hypertension.

In type 1 diabetes, the risk of nephropathy is strongly influenced by the level of blood pressure (BP). Ambulatory BP (ABP) monitoring has revealed an association between disturbed nocturnal BP drop and albuminuria and suggested a role of BP in microalbuminuria development. This study investigated the relationship between the urinary albumin excretion ratio (AER) and home BP (HBP) compared with ABP and clinical BP (CBP) measurements. A total of 50 adolescents and young adults with type 1 diabetes without hypertension or overt proteinuria (mean age 20+/-3.8 (s.d.) years, 21 male) had measurements of CBP (3 visits), HBP (6 days), 24-h ABP and AER (daytime and nighttime in the same 24 h with ABP monitoring). AER of 24 h was correlated with systolic 24-h (r=0.31), daytime (r=0.33) and nighttime ABP (r=0.36), without significant correlation with diastolic ABP, CBP or HBP (systolic or diastolic). Nighttime AER was correlated with 24-h (r=0.39/0.35, systolic/diastolic), daytime (r=0.36/0.32) and nighttime ABP (r=0.44/0.28). HBP was not associated with nighttime AER, but CBP was (diastolic BP only, r=0.41). No significant correlations were found between daytime AER and BP measurements. The nocturnal BP dip was not associated with any BP value. In non-dippers, nighttime AER showed strong correlations with ABP (24-h: r=0.45/0.42, systolic/diastolic; daytime: r=0.46/0.45; nighttime: r=0.49/0.35), HBP (r=0.34/0.31) and CBP (r=0.39/0.47). No such associations were found in dippers (r=0.05-0.10). These preliminary data suggest that in the early stage of diabetes-1, 24-h ABP monitoring seems to be the optimal method of revealing the association between BP and albuminuria, and cannot be replaced by HBP monitoring.

To determine ambulatory blood pressure (BP) means and distributions in an elderly population, we studied a random sample of 800 subjects stratified by sex and representative of residents aged 65 to 74 years of the city of Monza. Participation was 50%. Measurements consisted of clinic BP (average of three measurements with mercury sphygmomanometry), home BP (average of morning and evening measurements with a semiautomatic device), and ambulatory BP (SpaceLabs 90207). Clinic BP was obtained before and after home and ambulatory BP measurements. In normotensive and untreated hypertensive subjects (n=248), clinic, home, and ambulatory BPs were significantly related (P<.001). The means of the clinic BPs obtained on consecutive days were very similar and markedly higher than 24-hour average BP (+25 mm Hg systolic and + 10 mm Hg diastolic, P<.001). Nighttime BP was markedly less than daytime BP (-14 and -13 mm Hg, P<.001), whereas home BP values occurred approximately midway between clinic and 24-hour average BP values. Only minor differences existed between data in men and women, and the differences in clinic, home, and ambulatory BP values occurred in both normotensive and untreated hypertensive subjects. All BPs were similar in the untreated and treated hypertensive groups. Thus, as previously reported in subjects younger than 65 years, in the elderly fraction of the population, 24-hour average BP is much lower than clinic BP. The upper limit of normality for 24-hour average BP (calculated as the value corresponding to 140/90 mm Hg clinic BP) is about 120 mm Hg systolic and 76 mm Hg diastolic. At variance with data from younger subjects, home BP in the elderly is higher than 24-hour average BP. However, similar to data from younger subjects, clinic, home, and ambulatory BPs are higher in treated hypertensive than normotensive elderly subjects, indicating that in hypertensive elderly subjects, antihypertensive treatment does not commonly achieve full BP control both inside and outside the clinic environment.

To the Editor: We read with interest the paper by Sega et al regarding the prognostic value of ambulatory, home, and office blood pressure in the PAMELA population.1 However, we find that the main conclusions of the report may be driven by the lack of adjustment for confounders. The relationships between level of blood pressure and risk were not adjusted for age, which may have a major influence on risk over a long time span. There is indeed a relation between age and blood pressure,2 and therefore, these results may be biased. The comparisons of the various blood pressures were also not adjusted for potential confounders, with the argument that “no adjustment for age, sex, and other cardiovascular risk factors was made because comparisons between the predictive value of various blood pressure values involved the same sample.” However, it has been shown in a general Belgian population that the within-subject differences between office and ambulatory blood pressure measurements increased with older age and greater body mass index.3 In addition, in the Danish MONICA population, the within-subject differences between office and ambulatory blood pressure measurements increased with older age, diagnosis of hypertension, male gender, and presence of diabetes.4 So, to assess the true prognostic value of office blood pressure versus that of ambulatory blood pressure, it is mandatory to explore whether adjustments for other relevant cardiovascular risk factors would change the results. Recently, it was shown in the Danish MONICA population that ambulatory blood pressure was a much better predictor of all-cause mortality and cardiovascular mortality than office blood pressure, taking other relevant risk factors into account.5 Accordingly, to make the results from previous studies comparable to the PAMELA study, we would like to know the results of adjusted analyses. Until that time, the conclusion that …

To evaluate whether different hypertension phenotypes, namely, isolated systolic hypertension (ISH), isolated diastolic hypertension (IDH) and systolic/diastolic hypertension (SDH) have a differential outcome effect by clinic and ambulatory blood pressure (BP) measurements. We prospectively evaluated in 569 never-treated patients with sustained hypertension (age 52.6 ± 11.6 years; men 55%; clinic BP 150 ± 15/95.5 ± 10 mmHg, systolic/diastolic; 24-h ambulatory BP 128.9 ± 12.6/80.6 ± 9.7) the incidence of major cardiovascular (CV) events within 5 years, after adjustment for confounders, including the rate of BP control and the weighted follow-up BP. All participants received antihypertensive drug treatment (mean number of drugs 1.9 ± 1.1; follow-up visits 4.6/patient). Average clinic BP achieved during follow-up was 136 ± 12.6/83.9 ± 9.4 mmHg, with 39% of participants having clinic BP less than 140/90 mmHg in at least 75% of their visits, and 24% in 25-75% of visits. Prevalence of hypertension phenotypes defined using BP differed from that using ambulatory BP, whereas integration of both BP measurements reclassified the initial phenotype to another in 18% of participants. Although, no differential outcome effect was observed between clinic IDH and SDH assessed using clinic or ambulatory BP measurements, clinic BP-based ISH was associated with a higher outcome incidence than the IDH and SDH phenotypes (hazard ratio 4.8, 95% confidence interval 1.4-17.0, P = 0.015). ISH diagnosed by integration of clinic and ambulatory BP, also increased the outcome (hazard ratio 4.0, 95% confidence interval 1.0-15.6, P = 0.046). In hypertensive patients at low/moderate CV risk, IDH and SDH phenotypes defined by clinic BP measurements, equally determined CV events but to a lower extent compared with ISH.

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 …

Hypertension, the leading global risk factor for early mortality, cannot be detected or treated without accurate and practical methods of blood pressure (BP) measurement. Although home BP measurement has considerable popularity among patients, the lack of evidence needed to assure its place in modern clinical practice has hindered its widespread acceptance among physicians. This paper demonstrates that home BP measurement is more accurate than conventional clinic and ambulatory monitoring BP measurement and can be used effectively in clinical practice. On the basis of the data from different studies, it can be concluded that home BP measurement is an improvement over conventional clinic BP measurement. Home monitoring of BP is a convenient, accurate, and widely available option and may become the method of choice when diagnosing and treating hypertension. A paradigm shift is needed in BP measurement as evidence-based medicine suggests that clinic BP measurement should only be used for screening purposes.

Hypertension, the leading global risk factor for early mortality, cannot be detected or treated without accurate and practical methods of blood pressure (BP) measurement. Although home BP measurement has considerable popularity among patients, the lack of evidence needed to assure its place in modern clinical practice has hindered its widespread acceptance among physicians. This paper demonstrates that home BP measurement is more accurate than conventional clinic and ambulatory monitoring BP measurement and can be used effectively in clinical practice. On the basis of the data from different studies, it can be concluded that home BP measurement is an improvement over conventional clinic BP measurement. Home monitoring of BP is a convenient, accurate, and widely available option and may become the method of choice when diagnosing and treating hypertension. A paradigm shift is needed in BP measurement as evidence-based medicine suggests that clinic BP measurement should only be used for screening purposes.

Ambulatory blood pressure monitoring in clinical practice.

White-coat hypertension (HT) and masked HT can be identified by home blood pressure (BP) measurement. The prevalence of these subtypes and the associated risk of cardiovascular disease have not been fully investigated among Japanese hypertensive patients. The risk of cardiovascular events due to HT and its relationship with home BP measurement were examined among Japanese hypertensive patients receiving treatment in the Japan Hypertension Evaluation with Angiotensin II Antagonist Losartan Therapy (J-HEALTH) study, a nationwide prospective observational study. Both home and clinic BP were measured during treatment, and the occurrence of cardiovascular events was monitored in 4,596 Japanese patients (mean age of 60.8 years, 43.2% men, and mean follow-up period of 3.5 years). HT was defined as a systolic BP > or =140 mmHg for clinic BP and > or =135 mmHg for home BP while on treatment. The relative risk of all cardiovascular events and stroke increased along with higher clinic and home BP levels during treatment. The prevalence of white-coat HT, masked HT, well-controlled HT, and poorly controlled HT was 12.6%, 19.5%, 23.8%, and 44.1%, respectively. The relative risk of cardiovascular events was not significantly increased in the poorly controlled HT (relative risk [RR]: 2.05, 95% confidence interval [CI]: 0.77-5.45), white-coat HT (RR: 0.77, 95% CI: 0.15-3.96), and masked HT (RR: 2.00, 95% CI: 0.67-5.98) subgroups compared with the well-controlled-HT subgroup; however, the risk of masked HT was similar to that of poorly controlled HT. Monitoring both clinic and home BP is important to diagnose masked HT and to prevent cardiovascular disease in this subtype of HT. However, further investigation is required to fully characterize the cardiovascular risks associated with masked HT among Japanese patients receiving treatment.