Automated office blood pressure measurements obtained with and without preceding rest are associated with awake ambulatory blood pressure

Impact of Successive Office Blood Pressure Measurements During a Single Visit on Cardiovascular Risk Prediction: Analysis of CARTaGENE

BACKGROUND

Multiple office blood pressure (BP) readings correlate more closely with ambulatory BP than single readings. Whether they are associated with long-term outcomes and improve cardiovascular risk prediction is unknown. Our objective was to assess the long-term impact of multiple office BP readings.

METHODS

We used data from CARTaGENE, a population-based survey comprising individuals aged 40 to 70 years. Three BP readings (BP1, BP2, and BP3) at 2-minute intervals were obtained using a semiautomated device. They were averaged to generate BP1-2, BP2-3, and BP1-2-3 for systolic BP (SBP) and diastolic BP. Cardiovascular events (major adverse cardiovascular event [MACE]: cardiovascular death, stroke, and myocardial infarction) during a 10-year follow-up were recorded. Associations with MACE were obtained using adjusted Cox models. Predictive performance was assessed with 10-year atherosclerotic cardiovascular disease scores and their associated C statistics.

RESULTS

In the 17 966 eligible individuals, 2378 experienced a MACE during follow-up. Crude SBP values ranged from 122.5 to 126.5 mm Hg. SBP3 had the strongest association with MACE incidence (hazard ratio, 1.10 [1.05-1.15] per SD) and SBP1 the weakest (hazard ratio, 1.06 [1.01-1.10]). All models including SBP1 (SBP1, SBP1-2, and SBP1-2-3) were underperformed. At a given SBP value, the excess MACE risk conferred by SBP3 was 2× greater than SBP1. In atherosclerotic cardiovascular disease scores, SBP3 yielded the highest C statistic, significantly higher than most other SBP measures. In contrast to SBP, all diastolic BP readings yielded similar results.

CONCLUSIONS

Cardiovascular risk prediction is improved by successive office SBP values, especially when the first reading is discarded. These findings reinforce the necessity of using multiple office BP readings.

Use of unattended automated office blood pressure in Utah primary care clinics

AIM

Unattended automated office blood pressure (BP) measurement (u-AOBP) improves office BP measurement accuracy and reduces white-coat BP elevation. u-AOBP is recommended as the preferred office BP measurement technique by multiple hypertension guidelines. This study examines utilization, performance, and potential barriers to implementation of u-AOBP in Utah primary care clinics following 5 years of promotional efforts by the Utah Million Hearts Coalition (UMHC).

METHODS

An online questionnaire was administered to 285 Utah primary care clinics to evaluate self-reported use of u-AOBP and u-AOBP technique, interpretation of results, and perceived barriers to implementation.

RESULTS

Seventy-nine of 285 clinics (27.7%) completed the full questionnaire. Fifty-nine clinics (74.7%) use u-AOBP. Nearly 65% first learned about u-AOBP through UMHC promotional efforts rather than from the medical literature. One-half of these clinics noted no significant barriers to u-AOBP implementation, and over 80% noted no reduction in medical staff productivity. However, important knowledge deficits concerning correct u-AOBP performance and interpretation of results were apparent from answers to the questionnaire.

CONCLUSION

After 5 years of UMHC promotional efforts, at least 20% of the 285 Utah primary care clinics invited to take the questionnaire and 75% of the 79 clinics completing the survey have incorporated u-AOBP and found it feasible in a primary care setting. Ongoing promotion of u-AOBP implementation at the local and regional level is required to extend its utilization. Effective, accessible educational materials and local technical assistance from public health and community partners are needed to correct knowledge and performance deficits to optimize u-AOBP utilization in primary care.

Automated office blood pressure measurement by elderly patients in the waiting room

OBJECTIVE

Unattended automated office blood pressure (AOBP) may be a better estimate of true blood pressure (BP) than conventional office BP by physicians or nurses. However, measurement of AOBP is cumbersome in general clinical practice. We compared unattended AOBP by the patients themselves using the rigid cuff in the waiting room with attended AOBP and home BP (HBP) (N = 72).

METHODS

Unattended AOBP by patients was measured in the waiting room using a rigid cuff with the fully automated device (Omron, HEM-907, triple BP readings taken at 1-min intervals after 5 min of rest). Attended AOBP was measured using a soft cuff by a physician in an examination room without specific resting time. HBP was measured for 5 consecutive days.

RESULTS

The mean age was 76.5 ± 8.6 years. The mean systolic unattended AOBP by patients, attended AOBP and HBP were 139.3 ± 16.6, 144.8 ± 17.1 and 139.1 ± 14.4 mmHg, respectively. Unattended AOBP by patients was significantly related to attended AOBP (r = 0.798; P < 0.01) and to HBP (r = 0.404; P < 0.001). It was significantly lower than attended AOBP (difference 5.5 ± 10.7 mmHg; P < 0.001) and comparable with HBP (difference 0.26 ± 17.0 mmHg; P = 0.90) in Bland-Altman plots. However, 22% of patients had a difference of over 20 mmHg between unattended AOBP by patients and HBP. Multivariate regression demonstrated older age (B = -0.73; P = 0.002) to be related to the difference between unattended AOBP by patients and HBP.

CONCLUSION

The mean unattended AOBP by patients was lower than attended AOBP and comparable with HBP, but older age affected the difference between unattended AOBP by patients and HBP.

Clinical Impact of after-consult clinic blood pressure: comparison with automated office blood pressure

Background

It is most important to measure blood pressure (BP) exactly in treating hypertension. Recent recommendations for diagnosing hypertension clearly acknowledge that an increase in BP attributable to the “whitecoat response” is frequently associated with manual BP recordings performed in community-based practice.

However, there was no data about after-consult (AC) BP that could reduce whitecoat effect. So we evaluated before-consult (BC) and AC routine clinic BP and research based automated office blood pressure (AOBP) measured.

Methods

The study population consisted of 82 consecutive patients with hypertension between April 2019 and December 2019. We measured routine clinic BP and AOBP before and after see a doctor, respectively. Seated blood pressure and pulse are measured at each time after a rest period using an automated device as it offers reduced potential for observer biases. AOBP was measured and measuring BP 3 times un-observed. We compared each BP parameter for identifying exact resting BP state.

Results

There was significant difference between BC and AC systolic BP (135.37 ± 16.90 vs. 131.95 ± 16.40 mmHg, p = 0.015). However there was no difference in the BC and AC diastolic blood pressure (73.75 ± 11.85 vs. 74.42 ± 11.71 mmHg, p = 0.415). In the AOBP comparison, there was also significant difference (BC systolic AOBP vs. AC systolic AOBP, 125.17 ± 14.41 vs. 122.98 ± 14.09 mmHg, p = 0.006; BC diastolic ABOB vs. AC diastolic AOBP, 71.99 ± 10.49 vs. 70.99 ± 9.83, p = 0.038).

Conclusions

In our study, AC AOBP was most lowest representing resting state. Although AC BP was higher than BC AOBP, it might be used as alternative measurement for reducing whitecoat effect in the routine clinical practice.

Randomized Controlled Trial Comparing Automated Office Blood Pressure Readings After Zero or Five Minutes of Rest

[Figure: see text].

Unattended automated office blood pressure measurement: Time efficiency and barriers to implementation/utilization

Unattended automated office blood pressure (BP) measurement (u-AOBP) improves office BP measurement accuracy and reduces white-coat BP elevation, but there are reservations about its time efficiency in primary care. We used time-stamp methodology to measure u-AOBP procedure times performed without a rest period in 130 patients during routine clinic visits to three primary care clinics with 2.5-4.9 years u-AOBP experience. We documented the clinical activities of 30 medical assistants during the u-AOBP procedures. We also assessed MA and clinician satisfaction and knowledge about u-AOBP performance and interpretation. Median u-AOBP procedure time was <5 minutes, and MAs engaged in productive clinical activities during 83% of the procedures. Ninety-three percent of MAs and 100% of clinicians in the clinics agreed that u-AOBP is an efficient method to improve hypertension management. Barriers to effective u-AOBP implementation and ongoing utilization included initial difficulty incorporating u-AOBP into clinic workflow and medical staff knowledge deficiencies concerning correct u-AOBP performance and interpretation despite prior training and experience with the procedure. Intensive u-AOBP education and training programs are needed to facilitate effective u-AOBP implementation into primary care. The time required to perform u-AOBP can be utilized productively by staff.