Optimal schedule for home blood pressure monitoring based on a clinical approach

Home blood pressure monitoring schedule: optimal and minimum based on 2122 individual participants' data

OBJECTIVES

Home blood pressure (HBP) monitoring has become a primary method for hypertension diagnosis and management. This analysis aimed to investigate the optimal and minimum schedule for HBP monitoring.

METHODS

A retrospective analysis of cross-sectional data was performed, which involved HBP and 24-h ambulatory blood pressure (ABP) monitoring in adults performed within the context of clinical studies in Finland, Greece and UK. Participants with six to seven HBP monitoring days and at least 12 HBP readings were included. The stability of HBP was assessed by evaluating the average value of an increasing number of readings and its variability (SD). Its association with awake ABP was also assessed.

RESULTS

Data from 2122 participants were analysed (mean age 53.9 ± 11.3 years, males 53%, treated 34%). A progressive HBP decline was observed in succeeding days, reaching a plateau after day 3. Day 1 HBP was higher than in the next days by about 2.8/1.4 mmHg (systolic/diastolic, P < 0.001). In a 3-day HBP monitoring schedule, the exclusion of day 1 reduced average HBP and SD, with a clinically important HBP decline in 115 participants (5%) and different hypertension diagnosis in 120 participants (6%). For schedules including more than three HBP monitoring days, the exclusion of day 1 had negligible impact. The 3-day average HBP was strongly correlated with awake ABP, with a little improvement thereafter.

CONCLUSION

These data support the recommendation for 7 days of HBP monitoring with a minimum of 3 days. Readings of the first day should be discarded, particularly when the minimum 3-day monitoring schedule is obtained (average readings of second and third day).

Blood Pressure in Patients with Arterial Hypertension and Overweight or Obesity During Office Measurement and Daily Monitoring

Arterial hypertension (AH) is one of the most common chronic diseases in the world. More than 1.5 billion people suffer from hypertension. According to official statistics, in Ukraine in 2021 more than 13 million patients with AH were registered, and annually this disease is detected in 1 million Ukrainians. The objective: to determine the levels of blood pressure (BP) in overweighted or obese patients with AH who use antihypertensive drugs during office measurement and 24-hours monitoring of BP. Materials and methods. The study analyzed the results of treatment of 395 overweighted or obese patients (139 women and 236 men) with essential AH. All patients received antihypertensive treatment for at least 3 months before study start. Patients were divided into five groups depending on blood pressure. The control group included 33 age-matched individuals. During the study BP was measured in physician’s office with use of mechanical tonometer with a shoulder cuff and ambulatory 24-hours blood pressure monitoring (ABPM) was performed for all patients. Results. The results of office blood pressure measurement and ABPM were analyzed. Normal BP was detected in 34.7% of patients with AH and high BMI. In 10.9% of patients systolic blood pressure (SBP) remains above 139 mm Hg despite of drug use, in 16.3% of patients the grade 1 AH was diagnosed, in 23.2% – grade 2, and in 14.9% – grade 3 AH was deter mined during office blood pressure measurement. It was found that men are 1.7 times more likely had uncontrolled AH comparing to women. The further analyze of the BP data showed that office BP levels were higher then home. Target blood pressure levels were found in 87% of patients during ABPM, although in the office measurement this figure was 54%, 5% of patients could not withstand the BP monitoring during the day with an automatic device due to pain. No difference in heart rate was determined in study patients by different types of measurement. Conclusions. In patients with AH and high body mass index, office measurement reveals insufficient reduction of blood pressure (BP) in 35% of patients despite of antihypertensive drugs use. At the same time ABPM found target BP achievement in 87% of patients. Thus, ABPM should be performed in overweighted or obese patients with AH before making the decision to increase the antihypertensive drug dose to avoid possible undesirable BP decrease.

Home blood pressure monitoring: methodology, clinical relevance and practical application: a 2021 position paper by the Working Group on Blood Pressure Monitoring and Cardiovascular Variability of the European Society of Hypertension

The present paper provides an update of previous recommendations on Home Blood Pressure Monitoring from the European Society of Hypertension (ESH) Working Group on Blood Pressure Monitoring and Cardiovascular Variability sequentially published in years 2000, 2008 and 2010. This update has taken into account new evidence in this field, including a recent statement by the American Heart association, as well as technological developments, which have occurred over the past 20 years. The present document has been developed by the same ESH Working Group with inputs from an international team of experts, and has been endorsed by the ESH.

Within-Home Blood Pressure Variability on a Single Occasion Has Clinical Significance

There is growing evidence that diversely defined blood pressure variability (BPV) is an independent predictor of hypertensive target organ damage (TOD) and cardiovascular events. Several mechanisms have been speculated to underlie episodes of increased BPV, including the impairment of autonomic or hormonal regulation, renal dysfunction, and increased arterial stiffness. Within-home BPV, defined as differences in BP values obtained on a single occasion at home, could have prognostic significance for hypertensive TOD. It is typically thought that BP values are decreased with repeated measurements on a single occasion at home, but in the present subanalysis of 4,149 J-HOP (Japan Morning Surge-Home Blood Pressure) study patients, approximately 20% of the patients' home BP values were increased or unchanged by repeated measurements on a single occasion. In addition, those patients were likely to have hypertensive TOD. Thus, home BP measurement should be taken twice or more to detect the increase trend in home BP, which has been defined as within-home BPV.

Clinical Practice of Two Measurements of Home Blood Pressure on Each Occasion in Patients with Chronic Kidney Disease

BACKGROUND/AIMS

Although several guidelines propose two or three measurements of home blood pressure (HBP) on each occasion, the actual status of multiple measurements is not clear in the practical management of hypertension. We surveyed the details regarding two measurements of HBP in patients with chronic kidney disease (CKD).

METHODS

HBP was measured twice every morning and evening over 7 consecutive days in 175 CKD patients. The distribution of the differences between two BP values (2nd - 1st BP) and their association with BP parameters were evaluated.

RESULTS

The 2nd - 1st morning systolic BP (SBP) and diastolic BP (DBP) differences were -2.3 ± 4.1 and -0.4 ± 2.6 mm Hg, respectively. The proportion of 2nd - 1st morning SBP differences >0 mm Hg was 31.7% in a total of 1,195 measurements. Eighty patients (45.7%) had days with a difference ≤-5 mm Hg and days with a difference ≥5 mm Hg in morning SBP during 7 days. The multivariate regression analysis of the SD values of 2nd - 1st morning SBP as a dependent variable showed that the SD value of the 1st morning SBP (β = 0.65, p < 0.001) was a significant determinant.

CONCLUSION

Although the 2nd SBP was 2-3 mm Hg lower than the 1st SBP in the population as a whole, various differences were found for each subject during 7 days. 2nd - 1st BP variability might be associated with day-by-day 1st BP variability.

Increase Trend in Home Blood Pressure on a Single Occasion Is Associated With B-Type Natriuretic Peptide and the Estimated Glomerular Filtration Rate

BACKGROUND

Although obtaining multiple home blood pressure (HBP) measurements on a single occasion was recommended in European and Japanese hypertension guidelines, the clinical implications of the differences in BP measurements on a single occasion have been uncertain.

METHODS

Here, 4,149 patients with cardiovascular risk factors were enrolled. We asked the patients to measure their HBP 3 times on a single occasion each day over a 2-week period. We evaluated the target organ damage (TOD) indicators left ventricular mass index (LVMI), urinary albumin creatinine ratio, B-type natriuretic peptide (BNP), N-terminal pro-BNP (NT-pro BNP), high-sensitive cardiac troponin, brachial-ankle pulse wave velocity (ba PWV), intima-media thickness, and estimated glomerular filtration rate (eGFR). The associations between TOD and the difference between the first home systolic BP (SBP) value and the average of the second and third home SBP values were assessed by multiple regression analyses with adjustment for covariates.

RESULTS

Compared to the quintile median, the TOD of the first-quintile patients (i.e., those with elevated the second and third home SBP values compared to the first value) were significantly higher BNP, higher NT-pro BNP, higher ba PWV, and lower eGFR. In a univariate analysis of variance, compared to the median quintile, the first-quintile patients had independently and significantly higher BNP, higher NT-pro BNP, and lower eGFR.

CONCLUSION

The patients with elevated the second and third home SBP values compared to the first value taken on a single occasion were likely to have deteriorated BNP, NT-pro BNP, and eGFR.

Clinical significance of home blood pressure measurements for the prevention and management of high blood pressure

1. Ambulatory blood pressure (ABP) monitoring (M) provides BP information at many points on any particular day during unrestricted routine daily activities, whereas home blood pressure (HBP) monitoring provides a lot of BP information obtained under fixed times and conditions over a long period of time, thus mean values of HBP provide high reproducibility, and thus an overall superiority compared with ABP.  2. HBP is at least equally or better able than ABP to predict hypertensive target organ damage and prognosis of cardiovascular disease.  3. HBPM allows for ongoing disease monitoring by patients, improves adherence to antihypertensive treatment, and can provide health-care providers with timely clinical data and direct and immediate feedback regarding diagnosis and treatment of hypertension.  4. HBPM provides BP information in relation to time; that is, BP in the morning, in the evening and at night during sleep, and it is an essential tool for the diagnosis of white-coat and masked hypertension.  5. HBPM yields minimal alerting affects and no or minimal placebo effect, and can therefore distinguish small, but significant, serial changes in BP. It is thus the most practical method for monitoring BP in the day-to-day management of hypertension. 6. The superiority of HBPM over ABPM and clinic BPM is apparent from almost all practical and clinical research perspectives.

Comparisons of home and daytime ambulatory blood pressure measurements

Background

Home (HBPM) and ambulatory (ABPM) blood pressure measurements have their advantages and disadvantages in diagnosing and managing hypertension. We studied HBPMs and ABPMs in volunteers taking part in a survey.

Methods

Of 366 respondents, 270 provided a total of 5997 triplicate HBPMs (Part 1); 175 also provided data on ABPMs, of which the measurements obtained between 6 am and 10 pm were used in this study (Part 2).

Results

Part 1, When all 5997 triplicate HPPMs were considered, 1st readings tended to be significantly higher than those of the 2nd and 3^rd for both, systolic and diastolic pressures, but when the consideration was restricted to the very first triplicate of each of the 270 subjects, this was true only for systolic HBPM. Part 2, The ABPMs tended to have a wider range than the corresponding HBPMs, and to be distributed towards higher values. Of the non-parametric indices of (ABPM - corresponding HBPM), (First Quartile, Median, Third Quartile and Maximim) all but the minima had positive values.

Conclusions

In triplicate HBPMs, the first measurement is usually but not always the highest. Increasing the number of triplicates provided by each subject increases the chance of discriminating between measurements in the triplicates. ABPMs tended to be higher than the corresponding HBPMs.

Patient self-monitoring of blood pressure and self-titration of medication in primary care: the TASMINH2 trial qualitative study of health professionals' experiences

BACKGROUND

Self-monitoring with self-titration of antihypertensives leads to reduced blood pressure. Patients are keen on self-monitoring but little is known about healthcare professional views.

AIM

To explore health professionals' views and experiences of patient self-management, particularly with respect to future implementation into routine care.

DESIGN AND SETTING

Qualitative study embedded within a randomised controlled trial of healthcare professionals participating in the TASMINH2 trial of patient self-monitoring with self-titration of antihypertensives from 24 West Midlands general practices.

METHOD

Taped and transcribed semi-structured interviews with 13 GPs, two practice nurses and one healthcare assistant. Constant comparative method of analysis.

RESULTS

Primary care professionals were positive about self-monitoring, but procedures for ensuring patients measured blood pressure correctly were haphazard. GPs interpreted home readings variably, with many not making adjustment for lower home blood pressure. Interviewees were satisfied with patient training and arrangements for blood pressure monitoring and self-titration of medication during the trial, but less sure about future implementation into routine care. There was evidence of a need for training of both patients and professionals for successful integration of self-management.

CONCLUSION

Health professionals wanted more patient involvement in hypertension care but needed a framework to work within. Consideration of how to train patients to measure blood pressure and how home readings become part of their care is required before self-monitoring and self-titration can be implemented widely. As home monitoring becomes more widespread, the development of patient self-management, including self-titration of medication, should follow but this may take time to achieve.

Postprandial hypotension detected through home blood pressure monitoring: a frequent phenomenon in elderly hypertensive patients

Postprandial hypotension (PPH) is a frequently under-recognized entity associated with increased morbidity and mortality. The prevalence of PPH detected through home blood pressure monitoring (HBPM) is unknown. To determine the prevalence and clinical predictors of PPH in hypertensive patients assessed through HBPM. Hypertensive patients of 18 years or older underwent home blood pressure (BP) measurements (duplicate measurements for 4 days: in the morning, 1 h before and 1 h after their usual lunch, and in the evening; OMRON 705 CP). PPH was defined as a meal-induced systolic BP decrease of ≥20 mm Hg. Variables identified as relevant predictors of PPH were entered into a multivariate logistic regression analysis. In total, 230 patients were included in the analysis, with a median age of 73.6 (interquartile range 16.9) years, and 65.2% were female. The prevalence of PPH (at least one episode) was 27.4%. Four variables were independently associated with PPH: age of 80 years or older (odds ratio (OR) 3.45, 95% confidence interval (CI) 1.35-8.82), body mass index (BMI) (OR 0.88, 95%CI 0.81-0.96), office systolic BP (OR 1.03, 95%CI 1.01-1.05) and a history of cerebrovascular disease (OR 3.29, 95%CI 1.03-10.53). PPH after a typical meal is a frequent phenomenon that can be detected through HBPM. Easily measurable parameters in the office such as older age, higher systolic BP, lower BMI and a history of cerebrovascular disease may help to detect patients at risk of PPH who would benefit from HBPM.

Could home arterial stiffness index be a novel marker for arterial stiffness in patients with type 2 diabetes?

Recent studies suggested that home arterial stiffness index (HASI) may be a new measure of arterial stiffness. The aim of this study was to investigate whether HASI is more strongly associated with arterial stiffness than is pulse pressure (PP) and thus a more suitable tool than PP for evaluating arterial stiffness in patients with type 2 diabetes. We evaluated the relationship of HASI or PP with pulse wave velocity (PWV) as well as with major cardiovascular risk factors in 332 patients with type 2 diabetes. Furthermore, we compared the area under the receiver-operator characteristic curve (AUC) of HASI or PP for PWV. Morning PP was positively associated with PWV (r=0.303, P<0.0001), while morning HASI was not (r=-0.006, P=0.9063). Multiple regression analysis demonstrated that morning PP (β=0.179, P=0.0210), but not morning HASI (β=-0.040, P=0.5036), was independently associated with PWV. The AUCs (95% confidence interval (CI)) of morning HASI and morning PP for arterial stiffness were 0.510 (0.448-0.573) (P=0.745) and 0.638 (0.578-0.698) (P<0.0001), respectively. The AUC (95% CI) of morning HASI for arterial stiffness was significantly less than that of morning PP (P=0.0005). In conclusion, morning HASI is less correlated with PWV than is morning PP in patients with type 2 diabetes.

Home blood pressure variability on one occasion is a novel factor associated with arterial stiffness in patients with type 2 diabetes

Recent studies have suggested that not only mean blood pressure but also variability in blood pressure might be related to cardiovascular disease. The aim of this study was to investigate the association between home blood pressure variability on one occasion and markers of arterial stiffness in patients with type 2 diabetes. We investigated the relationship between the s.d. of clinic- or home-measured systolic blood pressure on one occasion and pulse wave velocity (PWV) in 332 patients with type 2 diabetes, and we evaluated whether the SD of clinic- or home-measured systolic blood pressure on one occasion was an independent determinant of PWV by multivariate linear regression analysis, after adjustment for known risk factors for arterial stiffness, including sex, age, duration of diabetes, body mass index, hemoglobin A1c, serum total cholesterol, triglycerides, smoking status, drinking alcohol, presence of antihypertensive medication, average systolic blood pressure and heart rate. Age, average morning home-measured systolic blood pressure, heart rate and PWV (r=0.259, P<0.0001) were positively correlated with the s.d. of morning home blood pressure on one occasion. Multiple regression analysis demonstrated that age, average morning home-measured systolic blood pressure (P=0.0019), heart rate and the s.d. of morning home-measured systolic blood pressure on one occasion (P=0.0159) were independently associated with PWV. In conclusion, home blood pressure variability on one occasion was correlated with PWV, independent of other known risk factors, in Japanese patients with type 2 diabetes.

Home versus ambulatory and office blood pressure in predicting target organ damage in hypertension: a systematic review and meta-analysis

OBJECTIVE

Studies have shown that ambulatory blood pressure (BP) is more closely related to preclinical target organ damage than office measurements. A review and meta-analysis of studies investigating the association of home BP measurements with target organ damage was performed.

METHODS

A PubMed and Cochrane Library search (1950-2011) revealed 23 studies reporting comparative data of home BP versus ambulatory and/or office measurements in terms of their association with several indices of target organ damage. Correlation coefficients were pooled by random-effects model meta-analysis.

RESULTS

Fourteen studies (n = 2485) assessing echocardiographic left ventricular mass index (LVMI) showed similar correlations with home (coefficients r = 0.46/0.28, systolic/diastolic) as with ambulatory BP (0.37/0.26, P = NS for difference versus home BP), and superior to office measurements (r = 0.23/0.19, P < 0.001/0.009 for difference versus home BP). Four methodologically heterogeneous studies assessing the glomerular filtration rate (n = 609) could not be pooled or lead to a concrete result. Four studies assessing carotid intima-media thickness (n = 1222), three assessing pulse wave velocity (n = 720) and two assessing urinary protein excretion (n = 156) showed no difference in pooled correlation coefficients with home versus office BP measurements. With all the measurement methods SBP was more closely associated with target organ damage than DBP.

CONCLUSION

These data suggest that home BP is as good as ambulatory monitoring and superior to office measurements in regard to their association with preclinical organ damage assessed by echocardiographic LVMI. More research is required to evaluate the relationship of home BP with other indices of target organ damage.

The coefficient variation of home blood pressure is a novel factor associated with macroalbuminuria in type 2 diabetes mellitus

The purpose of this study was to investigate the association between day-by-day variability in home blood pressure (HBP) on 14 consecutive days and macroalbuminuria in patients with type 2 diabetes. We compared the coefficient of variation (CV) of HBP in 858 Japanese patients with and without macroalbuminuria. Next, we analyzed the relationship between the logarithm of urinary albumin excretion (UAE) and the CV of HBP using linear regression analysis. Then, we evaluated the association between the CV of HBP and macroalbuminuria, defined as UAE ≥300 mg g(-1) creatinine, using logistic regression analysis. The CVs of morning and evening systolic blood pressure (SBP) were significantly greater in patients with macroalbuminuria than in those without (8.08±3.35 vs. 7.19±2.25%, P<0.05 and 9.01±3.58 vs. 7.98±2.57%, P<0.05, respectively). Multivariate linear regression analyses indicated that the CVs of morning SBP (P<0.05) and diastolic blood pressure (DBP; P<0.05), and those of evening SBP (P<0.05) were the independent explanatory variables for the logarithm of UAE. Multivariate logistic regression analyses also demonstrated that the odds ratio for the CVs of morning SBP, morning DBP and evening SBP for macroalbuminuria were 1.35 (P<0.05), 1.29 (P<0.05) and 1.44 (P<0.05), respectively. We conclude that the CV of HBP is correlated with macroalbuminuria, independent of the known risk factors, in Japanese patients with type 2 diabetes.

Optimal schedule for home blood pressure measurement based on prognostic data: the Finn-Home Study

Current guidelines based on cross-sectional statistical parameters derived from reference populations make equivocal recommendations for the optimal schedule of home blood pressure (BP) measurement. The objective of this study was to determine a schedule for home BP measurements in relation to their predictive value for total cardiovascular risk. Home BP was measured twice every morning and evening for 1 week in an unselected nationwide population of 2081 subjects aged 45 to 74 years. The prognostic significance of BP for fatal and nonfatal cardiovascular events was examined using adjusted Cox proportional hazards regression models. A total of 162 cardiovascular events were recorded during a 6.8-year follow-up. The predictive value of home BP increased progressively with the number of measurements, showing the highest predictive value with the average of all measurements (systolic/diastolic hazard ratio per 1-mm Hg increase in BP: 1.021/1.034; systolic/ diastolic 95% CI: 1.012 to 1.030/1.018 to 1.049). However, most of this increase was achieved during the first 3 days of measurement (hazard ratio: 1.017/1.028; 95% CI: 1.009 to 1.026/1.013 to 1.045), and only minimal increase occurred after day 6. No additional benefit was achieved by discarding the values obtained during the first day of measurement. Morning and evening BPs were equally predictive of future cardiovascular events. Novel prognostic data from this study show that measurement of home BP twice in the morning and evening, preferably for a period of 7 days, or for at least 3 days, provides a thorough image of a patient's BP level. This information should be used to prepare a unified international guideline for home BP measurement.

Reproducibility of masked hypertension in adults with untreated borderline office blood pressure: comparison of ambulatory and home monitoring

BACKGROUND

We examined short-term reproducibility of masked hypertension (MH) among adults with recent "borderline" office blood pressure (BP) and compared agreement of ambulatory BP monitoring (ABPM) and home BP monitoring (HBPM) in detecting MH.

METHODS

Fifty participants underwent repeated office BP measurements, 24-h ABPM, and HBPM sessions 1-week apart. Participants with office average <140/90 mm Hg were considered to have MH if daytime ABPM average was ≥135/85 mm Hg; they were considered to have MH by HBPM if the average was ≥135/85 mm Hg. Agreements were quantified using κ. We calculated sensitivity and specificity of daytime ABPM-office average pairing and HBPM session-office average pairing for diagnosing MH using a "standard" of two pairings of office and 24-h average ABPM (using a cutoff ≥130/80 mm Hg).

RESULTS

Prevalence rates of MH based on office-daytime ABPM pairings were 54 and 53%, with agreement of 73% (κ = 0.47; 95% confidence interval (CI) 0.21-0.72). MH was less prevalent (43 and 35%) using HBPM-office pairings, with agreement of 69% (κ = 0.34; 95% CI 0.06-0.62). Office-HBPM pairings and office-daytime ABPM pairings had poor agreement on MH classification on both occasions, with κ of -0.06 and 0.10. Sensitivity and specificity of daytime ABPM-office pairing were 93 and 83%. Sensitivity and specificity of HBPM-office pairing were 23 and 67%.

CONCLUSIONS

MH appears to have fair-to-moderate reproducibility, favoring the hypothesis that office BP measurement systematically fails to identify some patients who should be treated as hypertensive. HBPM may not be adequate for detecting MH, or may identify a different "type" of MH than ABPM.