Is home blood pressure monitoring useful in the management of patients with resistant hypertension? (original) (raw)
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Ambulatory Blood Pressure Monitoring in Resistant Hypertension
International Journal of Hypertension, 2011
ABPM constitutes a valuable tool in the diagnosis of RH. The identification of white coat RH and masked hypertension (which may fulfill or not the definition of RH) is of great importance in the clinical management of such patients. Moreover, the various ABPM components such as average BP values, circadian BP variability patterns, and ambulatory BP-derived indices, such as ambulatory arterial stiffness index (AASI), add significantly to the risk stratification of RH. Lastly, ABPM may indicate the need for implementation of specific therapeutic strategies, such as chronotherapy, that is, administration-time dependent therapy, and the evaluation of their efficacy.
Clinical practice of ambulatory versus home blood pressure monitoring in hypertensive patients
Blood Pressure Monitoring, 2015
Objectives This study aimed to analyze whether blood pressure (BP) measurement is concordant between ambulatory blood pressure monitoring (ABPM) and home blood pressure monitoring (HBPM), and determine whether the decision on treatment changes is similar on the basis of information provided by both methods. Methods Treated hypertensive patients were studied with ABPM and HBPM to evaluate therapeutic efficacy and/or diagnose resistant hypertension (HTN). Modification of pharmacological treatment was decided on the basis of preestablished criteria; therefore, the number of therapeutic changes between both techniques was compared. Results A total of 200 patients were included. The average daytime ABPM systolic blood pressure (SBP) was 136 ± 16 compared with 136 ± 15 (P = 1) with HBPM; the average diurnal diastolic blood pressure (DBP) was 83 ± 12 and 81 ± 9, respectively (P = 0.06). The concordance between both methods was very good for SBP [r = 0.85; Bland-Altman 0.2 (95% confidence interval 0.9-1.4 mmHg)], and good for the DBP [r = 0.77; Bland-Altman 1.8 (95% confidence interval 0.8-2.8 mmHg)]. Both methods were in agreement that HTN was controlled in 68 patients and that it was not controlled in 90 patients, that is, they were concordant in 158 patients (79%, κ = 0.6). More patients required changes with ABPM than HBPM (149 vs. 99 patients, P < 0.0001) Conclusion There were no significant differences in the measurement of diurnal SBP and DBP between both methods. The concordance to determine proper control of HTN was 79%. There was a significant difference in the decision to modify the treatment in favor of the ABPM.
Hypertension Research, 2012
Several studies with relatively small size and different design and end points have investigated the diagnostic ability of home blood pressure (HBP). This study investigated the usefulness of HBP compared with ambulatory monitoring (ABP) in diagnosing sustained hypertension, white coat phenomenon (WCP) and masked hypertension (MH) in a large sample of untreated and treated subjects using a blood pressure (BP) measurement protocol according to the current guidelines. A total of 613 subjects attending a hypertension clinic (mean age 53 ± 12.4 (s.d.) years, men 57%, untreated 59%) had measurements of clinic BP (three visits, triplicate measurements per visit), HBP (6 days, duplicate morning and evening measurements) and awake ABP (20-min intervals) within 6 weeks. Sustained hypertension was diagnosed in 50% of the participants by ABP and HBP (agreement 89%, j¼0.79), WCP in 14 and 15%, respectively (agreement 89%, j¼0.56) and MH in 16% and 15% (agreement 88%, j¼0.52). Only 4% of the subjects (27/613) showed clinically significant diagnostic disagreement with BP deviation 45 mm Hg above the diagnostic threshold (for HBP or ABP). By taking ABP as reference, the sensitivity, specificity, positive and negative predictive value of HBP in detecting sustained hypertension were 90, 89, 89 and 90%, respectively, WCP 61, 94, 64 and 94% and MH 60, 93, 60 and 93%. Similar diagnostic agreement was found in untreated and treated subjects. HBP appears to be a reliable alternative to ABP in the diagnosis of hypertension and the detection of WCP and MH in both untreated and treated subjects.
How to use ambulatory blood pressure monitoring in resistant hypertension
Hypertension Research, 2013
Resistant hypertension is defined as an uncontrolled office blood pressure (BP) despite the use of at least three antihypertensive drugs, in adequate doses and combinations, preferentially including one diuretic. It is a clinical diagnosis based on office BP measurements. Ambulatory BP monitoring (ABPM) is the cornerstone in the management of patients with resistant hypertension, as it is mandatory for diagnosis, treatment, follow-up and prognosis. In relation to diagnosis, ABPM measurements have classified patients with resistant hypertension into four subgroups: true, white-coat, controlled and masked resistant hypertension. This classification largely defines the therapeutic approach and the follow-up for each group. In this way, the target of antihypertensive treatment is ambulatory BP control and not office BP control. Chronotherapy based on ABPM values might frequently lead to a more rational treatment regimen. In relation to prognosis, uncontrolled ambulatory BP levels at baseline identify a subgroup of patients with a very high cardiovascular risk profile and a significantly worse prognosis. ABPM parameters can provide a better cardiovascular risk stratification than other traditional risk factors and office BPs.
Self-measured home blood pressure in predicting ambulatory hypertension
American journal of hypertension, 2004
Physicians are commonly uncertain whether a person with office blood pressure (BP) around 140/90 mm Hg actually has hypertension. This is primarily because of BP variability. One approach is to perform self-measured home BP and determine if home BP is elevated. There is a general agreement that if home BP is >/=135/85 mm Hg, then antihypertensive therapy may be commenced. However, some persons with home BP below this cut-off will have ambulatory hypertension. We therefore prospectively study the role of home BP in predicting ambulatory hypertension in persons with stage 1 and borderline hypertension. We studied in a cross-sectional way home and ambulatory BP in a group of 48 patients with at least two elevated office BP readings. The group was free of antihypertensive drug therapy for at least 4 weeks and performed 7 days of standardized self-BP measurements at home. We examined the relationships of the three BP methods and also defined a threshold (using receiver operating curve...
Hypertension, 2008
Home blood pressure monitoring (HBPM) overcomes many of the limitations of traditional office blood pressure (BP) measurement and is both cheaper and easier to perform than ambulatory BP monitoring. Monitors that use the oscillometric method are currently available that are accurate, reliable, easy to use, and relatively inexpensive. An increasing number of patients are using them regularly to check their BP at home, but although this has been endorsed by national and international guidelines, detailed recommendations for their use have been lacking. There is a rapidly growing literature showing that measurements taken by patients at home are often lower than readings taken in the office and closer to the average BP recorded by 24-hour ambulatory monitors, which is the BP that best predicts cardiovascular risk. Because of the larger numbers of readings that can be taken by HBPM than in the office and the elimination of the white-coat effect (the increase of BP during an office visit), home readings are more reproducible than office readings and show better correlations with measures of target organ damage. In addition, prospective studies that have used multiple home readings to express the true BP have found that home BP predicts risk better than office BP (Class IIa; Level of Evidence A). This call-to-action article makes the following recommendations: (1) It is recommended that HBPM should become a routine component of BP measurement in the majority of patients with known or suspected hypertension; (2) Patients should be advised to purchase oscillometric monitors that measure BP on the upper arm with an appropriate cuff size and that have been shown to be accurate according to standard international protocols. They should be shown how to use them by their healthcare providers; (3) Two to 3 readings should be taken while the subject is resting in the seated position, both in the morning and at night, over a period of 1 week. A total of Ն12 readings are recommended for making clinical decisions; (4) HBPM is indicated in patients with newly diagnosed or suspected hypertension, in whom it may distinguish between white-coat and sustained hypertension. If the results are equivocal, ambulatory BP monitoring may help to establish the diagnosis; (5) In patients with prehypertension, HBPM may be useful for detecting masked hypertension; (6) HBPM is recommended for evaluating the response to any type of antihypertensive treatment and may improve adherence; (7) The target HBPM goal for treatment is Ͻ135/85 mm Hg or Ͻ130/80 mm Hg in high-risk patients; (8) HBPM is useful in the elderly, in whom both BP variability and the white-coat effect are increased; (9) HBPM is of value in patients with diabetes, in whom tight BP control is of paramount importance; (10) Other populations in whom HBPM may be beneficial include pregnant women, children, and patients with kidney disease; and (11) HBPM has the potential to improve the quality of care while reducing costs and should be reimbursed. (Hypertension. 2008;52:000-000.)
Comparison of home and ambulatory blood pressure measurement in the diagnosis of masked hypertension
Journal of Hypertension, 2010
Objective: To evaluate whether home or ambulatory blood pressure (BP) monitoring was associated with preclinical hypertensive cardiovascular target organ damage (TOD). Methods: We enrolled participants with prehypertension and stage 1 hypertension from 11 medical centers within the Taiwan hypertension-associated cardiac disease consortium. Recordings of clinical BP measurement, ambulatory BP monitoring for 24 hours, and home BP monitoring during morning and evening were made. The measured parameters of target organ damage included left ventricular mass index (LVMI), left atrial volume index (LAVI), and carotid-femoral pulse wave velocity (PWV). Results: Data were collected from 561 study participants (mean age, 65.0 T 10.8 years; men, 61.3%). Morning and evening home BP values were slightly higher than the daytime and nighttime ABP values (difference for systolic morning-daytime/evening-nighttime, 7.3 T 14.2/11.3 T 18.5 mm Hg, P G .001; for diastolic, 5.4 T 9.4/ 7.3 T 12.1, P G .001). Daytime ambulatory (r = 0.114), nighttime ambulatory (r = 0.130), morning home (r = 0.310), and evening home (r = 0.220) systolic BPs (SBPs) were all associated with LVMI (all P G .05). The correlation coefficient was significantly greater for the relationship between daytime home SBP and LVMI than for the relationship between ambulatory SBP and LVMI (P G .01). The goodness of fit of the association between SBP and LVMI improved by adding home daytime SBP to the other SBPs (P G .001). Similar findings were observed for LAVI, but not for PWV. Conclusion: These findings indicate that morning SBP assessed by home monitoring appears to be a better predictor than other BP measures to determine preclinical hypertensive cardiovascular damage in patients with early-stage hypertension.
Integrated Blood Pressure Control, 2015
Our objective was to compare the clinical effectiveness of home blood pressure monitoring (HBPM) and 24-hour ambulatory blood pressure monitoring (ABPM) on blood pressure (BP) control and patient outcomes. Design: A systematic review was conducted. We also appraised the methodological quality of studies. Data sources: PubMed, Scopus, CINAHL, and the Cochrane Central Register of Control Trials (CENTRAL). Inclusion criteria: Randomized control trials, prospective and retrospective cohort studies, observational studies, and case-control studies published in English from any year to present that describe HBPM and 24-hour ABPM and report on systolic and/or diastolic BP and/or heart attack, stroke, kidney failure and/or all-cause mortality for adult patients. Due to the nature of the question, studies with only untreated patients were not considered. Results: Of 1,742 titles and abstractions independently reviewed by two reviewers, 137 studies met predetermined criteria for evaluation. Nineteen studies were identified as relevant and included in the paper. The common themes were that HBPM and ABPM correlated with cardiovascular events and mortality, and targeting HBPM or ABPM resulted in similar outcomes. Associations between BP measurement type and mortality differed by study population. Both the low sensitivity of office blood pressure monitoring (OBPM) to detect optimal BP control by ABPM and the added association of HBPM with cardiovascular mortality supported the routine use of HBPM in clinical practice. There was insufficient data to determine the benefit of using HBPM as a measurement standard for BP control. Conclusion: HBPM encourages patient-centered care and improves BP control and patient outcomes. Given the limited number of studies with both HBPM and ABPM, these measurement types should be incorporated into the design of randomized clinical trials within hypertensive populations.
American Journal of Hypertension, 2005
Background: The purpose of this study was to compare home and ambulatory blood pressure (BP) in the adjustment of antihypertensive treatment. Methods: After a 4-week washout period, patients whose untreated daytime diastolic ambulatory BP averaged Ն85 mm Hg were randomized to be treated according to their ambulatory or home BP. Antihypertensive treatment was adjusted at 6-week intervals according to the mean daytime ambulatory diastolic BP or the mean home diastolic BP, depending on the patient's randomization group. If the diastolic BP stayed above 80 mm Hg, the physician blinded to randomization intensified hypertensive treatment. Results: Ninety-eight patients completed the study. During the 24-week follow-up period both systolic and diastolic BP decreased significantly within both groups (P Ͻ .001). At the end of the study, the systolic/diastolic differences between ambulatory (n ϭ 46) and home (n ϭ 52) BP groups in home, daytime ambulatory, night-time ambulatory, and 24-h ambulatory BP changes averaged 2.6/2.6 mm Hg, 0.6/1.7 mm Hg, 1.0/1.4 mm Hg, and 0.6/1.5 mm Hg, respectively (P range .06 to .75) A nonsignificant trend to more intensive drug therapy in the ambulatory BP group and a nonsignificant trend to larger share of patients reaching (57.7% v 43.5%, P ϭ .16) the target pressure in the home BP group was observed due to the 3.8 mm Hg difference in ambulatory and home diastolic BP at randomization. Conclusions: The adjustment of antihypertensive treatment based on either ambulatory or home BP measurement led to good BP control. No significant betweengroup differences in BP changes were seen at the end of the study. Additional research is needed to provide more conclusive results.