Home versus ambulatory blood pressure monitoring in the diagnosis of clinic resistant and true resistant hypertension

Role of home blood pressure monitoring in resistant hypertension

The definition of resistant hypertension (RHT) has been updated to include failure to achieve target blood pressure (BP) despite treatment with ≥3 antihypertensive drugs, including diuretics, renin-angiotensin system blockers, and calcium channel blockers, prescribed at the maximum or maximally tolerated doses, or as success in achieving the target blood pressure but requiring ≥4 drugs. RHT is a major clinical problem, as it is associated with higher mortality and morbidity than non-RHT. Therefore, it is crucial to accurately identify RHT patients to effectively manage their disease. Out-of-clinic BP measurement, including home BP monitoring and ambulatory BP monitoring is gaining prominence for the diagnosis and management of RHT. Home BP monitoring is advantageous as it is feasibly repetitive, inexpensive, widely available, and because of its reproducibility over long periods. In addition, home BP monitoring has crucial advantage of allowing safe titration for the maximum or maximally tolerable dose, and for self-monitoring, thereby improving clinical inertia and nonadherence, and allowing true RHT to be more accurately identified.

Home blood pressure self-measurement: “Current situation and new perspectives”

The method typically used to diagnose and monitor hypertensive patients has been to measure blood pressure in the physician's surgery; however, it is a well-known fact that this approach poses certain drawbacks, such as observer bias, failure to detect an alert reaction in the clinic, etc., difficulties that affect its accuracy as a diagnostic method. In recent years, the varying international scientific societies have persistently recommended the use of blood pressure measurements outside the clinic (at home or in the outpatient setting), using validated automatic devices. Data from some studies suggest that if we rely solely on in-office measurements, approximately 15-20% of the time we may be wrong when making decisions, both in terms of diagnosis and patient follow-up. Home blood pressure measurements are a simple and very affordable method that has a similar reproducibility and prognostic value as ambulatory blood pressure monitoring, the availability of which is currently very limited. Moreover, ambulatory self-measurements have the significant benefit of being able to improve control of hypertensive individuals. Healthcare professionals and patients should be aware of the methodology of home blood pressure measurement, its usefulness and limitations.

Prognostic Impact of Home Blood Pressures for Adverse Cardiovascular Outcomes and Mortality in Patients With Resistant Hypertension: A Prospective Cohort Study

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Direct Comparison of Home Versus Ambulatory Defined Nocturnal Hypertension for Predicting Cardiovascular Events

The home blood pressure monitoring (HBPM) method that measures blood pressure during sleep hours was reported to be comparable to ambulatory blood pressure monitoring (ABPM) in measuring nighttime blood pressure and detecting nocturnal hypertension. The aim of this study was to directly compare the prognostic power of nocturnal hypertension detected by HBPM versus ABPM for predicting future cardiovascular events. We analyzed nighttime blood pressure (measured by HBPM and ABPM) data of 1005 participants who were included in the J-HOP study (Japan Morning Surge-Home Blood Pressure). During a follow-up period of 7.6±3.4 years, 80 cardiovascular disease events occurred. The majority (91.8%) of our study population were hypertensive, and 80.7% of participants were using antihypertensive medication. Nighttime home systolic blood pressure (SBP) was higher compared to nighttime ambulatory SBP (123.0±14.6 versus 120.3±14.4 mm Hg, P <0.001). Nocturnal hypertension was defined as nighttime home or ambulatory SBP of ≥120 mm Hg. The number of participants with nocturnal hypertension defined by HBPM and ABPM was 564 (56.1%) and 469 (46.7%), respectively. Nocturnal hypertension defined by HBPM was associated with increased risk of future cardiovascular events: total cardiovascular events (coronary artery disease and stroke events; 1.78 [1.00–3.15]) and stroke (2.65 [1.14–6.20]), independent of office SBP. These results were absent with nocturnal hypertension defined by ABPM. This is the first comparison prospective study illustrating that uncontrolled nocturnal hypertension defined by HBPM (independent of office SBP) is a predictor of future cardiovascular events.

Blood pressure differences between home monitoring and daytime ambulatory values and their reproducibility in treated hypertensive stroke and TIA patients

BACKGROUND

Guidelines recommend ambulatory or home blood pressure monitoring to improve hypertension diagnosis and monitoring. Both these methods are ascribed the same threshold values, but whether they produce similar results has not been established in certain patient groups.

METHODS

Adults with mild/moderate stroke or transient ischemic attack (N = 80) completed 2 sets of ambulatory and home blood pressure monitoring. Systolic and diastolic blood pressure values from contemporaneous measurements were compared, and the limits of agreement were assessed. Exploratory analyses for predictive factors of any difference were conducted.

RESULTS

Daytime ambulatory blood pressure values were consistently lower than home values, the mean difference in systolic blood pressure for initial ambulatory versus first home monitoring was -6.6 ± 13.5 mm Hg (P≤.001), and final ambulatory versus second home monitoring was -7.1 ± 11.0mm Hg (P≤.001). Mean diastolic blood pressure differences were -2.1 ± 8.5mm Hg (P=.03) and -2.0 ± 7.2mm Hg (P=.02). Limits of agreement for systolic blood pressure were -33.0 to 19.9mm Hg and -28.7 to 14.5mm Hg for the 2 comparisons and for DBP were -18.8 to 14.5mm Hg and -16.1 to 12.2mm Hg, respectively. The individual mean change in systolic blood pressure difference was 11.0 ± 8.3mm Hg across the 2 comparisons. No predictive factors for these differences were identified.

CONCLUSIONS

Daytime ambulatory systolic and diastolic blood pressure values were significantly lower than home monitored values at both time points. Differences between the 2 methods were not reproducible for individuals. Using the same threshold value for both out-of-office measurement methods may not be appropriate in patients with cerebrovascular disease.

What is the evidence base for diagnosing hypertension and for subsequent blood pressure treatment targets in the prevention of cardiovascular disease?

Diagnosing and treating hypertension plays an important role in minimising the risk of cardiovascular disease and stroke. Early and accurate diagnosis of hypertension, as well as regular monitoring, is essential to meet treatment targets. In this article, current recommendations for the screening and diagnosis of hypertension are reviewed. The evidence for treatment targets specified in contemporary guidelines is evaluated and recommendations from the USA, Canada, Europe and the UK are compared. Finally, consideration is given as to how diagnosis and management of hypertension might develop in the future.

Is home blood pressure monitoring useful in the management of patients with resistant hypertension?

BACKGROUND

Ambulatory blood pressure (BP) monitoring (ABPM) is a cornerstone in resistant hypertension (RHT) management. However, it has higher cost and lower patients' acceptance than home BP monitoring (HBPM). Our objective was to evaluate HBPM usefulness in the management of patients with RHT.

METHODS

A total of 240 patients were submitted to 24-hour ABPM and 5-day HBPM (triplicate morning and evening measurements). Patients with uncontrolled office BP (≥140/90mm Hg) were classified as true RHT (daytime or home BP ≥135/85mm Hg) or white-coat RHT (daytime or home BP <135/85mm Hg), and patients with controlled office BP were classified as masked RHT (daytime or home BP ≥135/85mm Hg) or controlled RHT (daytime or home BP <135/85mm Hg). Sensitivity, specificity, predictive values, and likelihood ratios for HBPM were calculated. Agreement between the procedures was evaluated using kappa coefficients and the Bland-Altman method.

RESULTS

Mean office BP was 157±26/84±16mm Hg, mean daytime BP was 134±18/77±13mm Hg, and mean home BP was 143±20/76±14mm Hg. The ABPM and HBPM diagnoses were 35% and 48%, respectively, for true RHT; 36% and 23%, respectively, for white-coat RHT; 7% and 17%, respectively, for masked RHT; and 22% and 13%, respectively, for controlled RHT. HBPM overestimated systolic BP by 8.8 (95% confidence interval (CI) = 6.8-10.7) mm Hg and diastolic BP by 0.2 (95% CI = -1.0 to 1.4) mm Hg. The specificity, sensitivity, and positive and negative predictive values of HBPM in detecting controlled ambulatory BP were 91%, 55%, 89%, and 59%.

CONCLUSIONS

HBPM presented good agreement with ABPM and can be used as a complementary method in the follow-up of resistant hypertensive patients, particularly in those with controlled ambulatory BPs.

Home blood pressure monitoring in heart transplant recipients: comparison with ambulatory blood pressure monitoring

BACKGROUND

How reliable is home blood pressure monitoring (HBPM) in heart transplant recipients is not known. Possibly, it may underestimate hypertensive burden, because blood pressure (BP) nondipper profile is frequent among these patients. This prospective study has been designed to determine whether HBPM adequately identifies hypertension in heart transplant recipients.

METHOD

We compared HBPM with ambulatory blood pressure monitoring (ABPM) for the diagnosis of uncontrolled hypertension in 74 patients 13.5±6.7 years after heart transplantation. HBPM was measured with a validated semiautomatic device twice every morning and twice every evening on 7 consecutive days, within 15 days of ABPM. We also measured the relationship between HBPM, ABPM, and organ damage as measured by albuminuria and left ventricular mass.

RESULTS

A nondipper profile was found in 53 (72%) patients. HBPM and ABPM were close according to Pearson bivariate correlations. There was no significant correlation between left ventricular mass and BP either at HBPM or ABPM. Proteinuria significantly correlated with systolic BP either at HBPM (R=0.42; P=0.0002) or ABPM (R=0.25; P=0.03). HBPM adequately classified 61 of 74 (82%) patients as hypertensives or as nonhypertensives or controlled hypertensives.

CONCLUSION

Despite a high prevalence of nondipper profile, HBPM gives a reliable estimate of BP burden in most heart transplant recipients. Thus, our results strongly suggest that HBPM is useful for the long-term follow-up of heart transplant recipients.

Home and ambulatory blood pressure in resistant hypertension

Since their introduction in the clinical setting home and ambulatory blood pressure measurements have gained growing popularity in the diagnosis and treatment of essential hypertension for a number of reasons. These reasons include: 1) the lack of the so-called "white-coat effect", 2) the ability of the two approaches to provide information on blood pressure phenomena of prognostic value, and 3) the close relationship of the derived values with the risk of developing fatal and non-fatal cardiovascular events. These features also apply to resistant hypertension, in which these approaches allow a precise definition of the diagnosis of this clinical condition, by excluding the presence of white-coat hypertension. Assessment of "out-of-office" blood pressure also allows us to define the patterns of blood pressure variability in this clinical condition as well as its relationships with target organ damage. Finally, home as well as ambulatory blood pressure measurements allow us to investigate the effects of therapeutic interventions, including those associated with the radiofrequency ablation of renal nerves. The present paper will provide a critical review of the main features of home and ambulatory blood pressure measurement in resistant hypertension, highlighting their main advantages as compared to office blood pressure. The prognostic significance, relationships with target organ damage and implications for treatment will also be discussed.

Use of ambulatory blood pressure monitoring to guide hypertensive therapy

OPINION STATEMENT

With the advent of noninvasive 24-hour ambulatory blood pressure monitoring (ABPM), clinicians have access to a wealth of individualized data for the hypertensive patient. This has led to a greater understanding of the pathophysiology of hypertension and its complications. This tool has provided more precise diagnostic criteria for hypertension and helped discover those with white coat and masked hypertension. Patterns noted on ABPM and correlated with outcomes have allowed for more accurate identification of patients at high risk of cardiovascular (CV) events, and have offered an additional prognostic tool. In addition, ABPM allows for the assessment of the efficacy and adequacy of blood pressure treatment. In the current paper, we will describe the essential components of ABPM, review the evidence detailing the prognostic information that can be derived from its use, highlight clinical scenarios wherein ABPM can offer invaluable diagnostic information, and describe applications of ABPM that evaluate the efficacy of treatment of the hypertensive patient.