The great myth of office blood pressure measurement

Clinical practice guidelines have traditionally recommended manual blood pressure (BP) measurement in the office setting as the standard method for diagnosing hypertension. In reality, manual BP in routine clinical practice is relatively inaccurate, over-diagnoses hypertension by provoking office-induced increases in BP and correlates poorly with both the awake ambulatory BP and target organ damage. The most recent guidelines recommend 24-h ambulatory BP and home BP for diagnosing hypertension. The advent of automated office BP (AOBP) represents a third alternative to conventional manual BP measurement, one that maintains the role of office BP readings in the diagnosis and management of hypertension. AOBP has three basic principles: multiple readings taken using a fully automated sphygmomanometer with the patient resting quietly alone. AOBP eliminates office-induced hypertension such that the cut-point for a normal AOBP is the same as for the awake ambulatory BP and home BP. As compared to routine manual office BP, AOBP provides more accurate BP readings, is more consistent during repeated office visits and in different settings and correlates better with both the awake ambulatory BP and target organ damage. The advantages of AOBP over manual BP measurement support its use in routine clinical practice.     

BpTRUth: Do automated blood pressure monitors outperform mercury?

Manual measurement of blood pressure (BP) in the office (MOBP) is inferior in accuracy when compared with ambulatory BP measurements (ABPM) since it misses white coat and masked effects on BP. BpTRU, an automated office BP device (AOBP), has been reported to reduce white coat effect. We performed a retrospective review of the diagnostic accuracy of MOBP (taken by a trained nurse in clinical hypertension) and AOBP using the Bland-Altman method in hypertensive patients referred to a Renal Hypertension Clinic. In 329 hypertensive patients, the 95% limits of agreement between systolic AOBP and ABPM were ?31 mm Hg to 33 mm Hg and for MOBP and ABPM were ?27.8 mm Hg to 37.4 mm Hg. The bias between systolic MOBP and systolic ABPM was 4.9 mm Hg (95% confidence interval, 3.0–6.6 mm Hg) whereas the bias between the systolic AOBP and the systolic ABPM was ?3.2 (95% confidence interval, ?1.3 to ?5.0). AOBP did not improve treatment relevant classification errors compared with MOBP (28% vs. 23%; P = .052). Our data support findings by others showing that AOBP improves, but does not eliminate, white coat effect. The increased detection of white coat effect appears related to systematic downward bias by BpTRU. As a result, detection of masked effect is undermined by BpTRU.     

Eliminating the Human Factor in Office Blood Pressure Measurement

Factors related to the physician/nurse and patient and their interaction are potential sources of error in manual office blood pressure (MOBP). The use of automated sphygmomanometers to record blood pressure (BP) with the patient alone reduces measurement error and minimizes anxiety‐related increases in BP, thus eliminating the “white‐coat” response. Comparative studies have shown the cut‐point for a normal automated office BP (AOBP), awake ambulatory BP, and home BP (<135/85 mmHg) to be similar, providing the patient does not rest for a prolonged period before the first AOBP reading, as recommended for MOBP measurement. AOBP should now replace MOBP in routine clinical practice.     

Comparison of awake ambulatory blood pressure and automated office blood pressure using linear regression analysis in untreated patients in routine clinical practice

The recent American hypertension guidelines recommended a threshold of 130/80 mmHg to define hypertension on the basis of office, home or ambulatory blood pressure (BP). Despite recognizing the potential advantages of automated office (AO)BP, the recommendations only considered conventional office BP, without providing supporting evidence and without taking into account the well documented difference between office BP recorded in research studies versus routine clinical practice, the latter being about 10/7 mmHg higher. Accordingly, we examined the relationship between AOBP and awake ambulatory BP, which the guidelines considered to be a better predictor of future cardiovascular risk than office BP. AOBP readings and 24‐hour ambulatory BP recordings were obtained in 514 untreated patients referred for ambulatory BP monitoring in routine clinical practice. The relationship between mean AOBP and mean awake ambulatory BP was examined using linear regression analysis with and without adjustment for age and sex. Special attention was given to the thresholds of 130/80 and 135/85 mmHg, the latter value being the recognized threshold for defining hypertension using awake ambulatory BP, home BP and AOBP in other guidelines. The mean adjusted AOBP of 130/80 and 135/85 mmHg corresponded to mean awake ambulatory BP values of 132.1/81.5 and 134.4/84.6 mmHg, respectively. These findings support the use of AOBP as the method of choice for determining office BP in routine clinical practice, regardless of which of the two thresholds are used for diagnosing hypertension, with an AOBP of 135/85 mmHg being somewhat closer to the corresponding value for awake ambulatory BP.     

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.     

Automated office blood pressure

Manual blood pressure (BP) is gradually disappearing from clinical practice with the mercury sphygmomanometer now considered to be an environmental hazard. Manual BP is also subject to measurement error on the part of the physician/nurse and patient-related anxiety which can result in poor quality BP measurements and office-induced (white coat) hypertension. Automated office (AO) BP with devices such as the BpTRU (BpTRU Medical Devices, Coquitlam, BC) has already replaced conventional manual BP in many primary care practices in Canada and has also attracted interest in other countries where research studies using AOBP have been undertaken. The basic principles of AOBP include multiple readings taken with a fully automated recorder with the patient resting alone in a quiet room. When these principles are followed, office-induced hypertension is eliminated and AOBP exhibits a much stronger correlation with the awake ambulatory BP as compared with routine manual BP measurements. Unlike routine manual BP, AOBP correlates as well with left ventricular mass as does the awake ambulatory BP. AOBP also simplifies the definition of hypertension in that the cut point for a normal AOBP (< 135/85 mm Hg) is the same as for the awake ambulatory BP and home BP. This article summarizes the currently available evidence supporting the use of AOBP in routine clinical practice and proposes an algorithm in which AOBP replaces manual BP for the diagnosis and management of hypertension.     

The optimal use of automated office blood pressure measurement in clinical practice

This evidence‐based article endorses the use of automated office blood pressure (AOBP). AOBP is the most favorable office blood pressure (BP) measuring technique as it provides accurate readings with 3‐15 mm Hg lower values than the casual conventional office measurements with auscultatory or semi‐automated oscillometric devices and relates closely to awake ABP readings. The AOBP technique seems to be superior to conventional office BP in predicting hypertension‐mediated organ damage and appears to be equally reliable to awake ABP in the prediction of cardiovascular (CV) disease. AOBP readings should be obtained either unattended, with the patient alone in the examination room, or attended with the presence of personnel in the room but with no talking to the patient, although this recommendation is not frequently followed in routine clinical practice. To optimize office BP readings, the type of device, the rest period before AOBP measurements (preceding rest), and the time intervals between measurements were evaluated. As AOBP readings have the advantage of removing many confounding factors, the authors propose to perform measurements with a preceding rest in all patients at the initial visit; if AOBP readings remain <130 mm Hg in subsequent visits, measurements could be accepted, otherwise, if are higher, patients should be evaluated by out‐of‐office BP measurements.     

Blood pressure measurement: Should technique define targets?

Accurate assessment of blood pressure (BP) is the cornerstone of hypertension management. The objectives of this study were to quantify the effect of medical personnel presence during BP measurement by automated oscillometric BP (AOBP) and to compare resting office BP by AOBP to daytime average BP by 24‐h ambulatory BP monitoring (ABPM). This study is a prospective randomized cross‐over trial, conducted in a referral population. Patients underwent measurements of casual and resting office BP by AOBP. Resting BP was measured as either unattended (patient alone in the room during resting and measurements) or as partially attended (nurse present in the room during measurements) immediately prior to and after 24‐h ABPM. The primary outcome was the effect of unattended 5‐min rest preceding AOBP assessment as the difference between casual and resting BP measured by the Omron HEM 907XL. Ninety patients consented and 78 completed the study. The mean difference between the casual and Omron unattended systolic BP was 7.0 mm Hg (95% confidence interval [CI] 4.5, 9.5). There was no significant difference between partially attended and unattended resting office systolic BP. Resting office BP (attended and partially attended) underestimated daytime systolic BP load from 24‐h ABPM. The presence or absence of medical personnel does not impact casual office BP which is higher than resting office AOBP. The requirement for unattended rest may be dropped if logistically challenging. Casual and resting office BP readings by AOBP do not capture the complexity of information provided by the 24‐h ABPM.     

Masked hypertension and target organ damage in treated hypertensive patients

BACKGROUND: Recent studies have shown that an elevated ambulatory or home blood pressure (BP) in the absence of office BP-a phenomenon called masked hypertension-is associated with poor cardiovascular prognosis. However, it remains to be elucidated how masked hypertension modifies target organ damage in treated hypertensive patients. METHODS: A total of 332 outpatients with chronically treated essential hypertension were enrolled in the present study. Patients were classified into four groups according to office (<140/90 or >or=140/90 mm Hg) and daytime ambulatory (<135/85 or >or=135/85 mm Hg) BP levels; ie, controlled hypertension (low office and ambulatory BP), white-coat hypertension (high office but low ambulatory BP), masked hypertension (low office but high ambulatory BP), and sustained hypertension (high office and ambulatory BP). Left ventricular mass index, carotid maximal intima-media thickness, and urinary albumin levels were determined in all subjects. RESULTS: Of the patients, 51 (15%), 65 (20%), 74 (22%), and 142 (43%) were identified as having controlled hypertension, white-coat hypertension, masked hypertension, and sustained hypertension, respectively. Left ventricular mass index, maximal intima-media thickness, and urinary albumin level in masked hypertension were significantly higher than in controlled hypertension and white-coat hypertension, and were similar to those in sustained hypertension. Multivariate regression analyses revealed that the presence of masked hypertension was one of the independent determinants of left ventricular hypertrophy, carotid atherosclerosis, and albuminuria. CONCLUSIONS: Our findings indicate that masked hypertension is associated with advanced target organ damage in treated hypertensive patients, comparable to that in cases of sustained hypertension.     

Predictive factors for masked hypertension within a population of controlled hypertensives

CONTEXT: Prevalence of masked hypertension (MH) is far from negligible reaching 40% in some studies. The SHEAF study (Self measurement of blood pressure at Home in the Elderly: Assessment and Follow-Up) and others clearly showed that masked hypertension (MH) as detected by home blood pressure measurement (HBPM) is associated with poor cardiovascular prognosis. OBJECTIVE: Systematic HBPM to detect MH is not yet routine. The aim of this work is to better define the clinical profile of masked hypertensives within a population with controlled office blood pressure (BP) and the factors associated with a higher prevalence of MH. MATERIALS AND METHODS: BP was measured at the clinic by the doctor and at home by the patient himself. Risk factors for MH were analysed in a cohort of 1150 treated hypertensive patients over the age of 60 (mean age 70 +/- 6.5, 48.9% men) with controlled office BP. (SBP < 140 mmHg and DBP < 90 mmHg). RESULTS: 463 patients (40%) were masked hypertensives (SBP > or = 135 mmHg or DBP > or = 85 mmHg at home). Three parameters were associated with MH (odds ratio OR): office SBP (OR = 1.110), male gender (OR = 2.214) and age (OR = 1.031). Decision trees showed a 130 mmHg SBP was an efficient threshold to propose HBPM with a higher probability to detect MH. Subsequent variables were male gender and age over 70 in males. CONCLUSION: To detect masked hypertension, it would be logical to first of all select patients whose office SBP is between 130 and 140 mmHg.     

Office blood pressure threshold of 130/80 mmHg better predicts uncontrolled out‐of‐office blood pressure in apparent treatment‐resistant hypertension

The objective of this study was to compare the diagnostic accuracy of office blood pressure (BP) threshold of 140/90 and 130/80 mmHg for correctly identifying uncontrolled out‐of‐office BP in apparent treatment‐resistant hypertension (aTRH). We analyzed 468 subjects from a prospectively enrolled cohort of patients with resistant hypertension in South Korea (clinicaltrials.gov: {"type":"clinical-trial","attrs":{"text":"NCT03540992","term_id":"NCT03540992"}}NCT03540992). Resistant hypertension was defined as office BP ≥ 130/80 mmHg with three different classes of antihypertensive medications including thiazide‐type/like diuretics, or treated hypertension with four or more different classes of antihypertensive medications. We conducted different types of BP measurements including office BP, automated office BP (AOBP), home BP, and ambulatory BP. We defined uncontrolled out‐of‐office BP as daytime BP ≥ 135/85 mmHg and/or home BP ≥ 135/85 mmHg. Among subjects with office BP < 140/90 mmHg and subjects with office BP < 130/80 mmHg, 66% and 55% had uncontrolled out‐of‐office BP, respectively. The prevalence of controlled and masked uncontrolled hypertension was lower, and the prevalence of white‐coat and sustained uncontrolled hypertension was higher, with a threshold of 130/80 mmHg than of 140/90 mmHg, for both office BP and AOBP. The office BP threshold of 130/80 mmHg was better able to diagnose uncontrolled out‐of‐office BP than 140/90 mmHg, and the net reclassification improvement (NRI) was 0.255. The AOBP threshold of 130/80 mmHg also revealed better diagnostic accuracy than 140/90 mmHg, with NRI of 0.543. The office BP threshold of 130/80 mmHg showed better than 140/90 mmHg in terms of the correspondence to out‐of‐office BP in subjects with aTRH.     

Comparison between unattended automated office blood pressure and conventional office blood pressure under the environment of health checkup among Japanese general population

Unattended automated office blood pressure (AOBP) measurement has been endorsed as the preferred in‐office measurement modality in recent Canadian and American clinical practice guidelines. However, the difference between AOBP and conventional office blood pressure (CBP) under the environment of a health checkup remains unclear. We aimed to identify the clinical significance of AOBP as compared to CBP under the environment of a health checkup. There were 491 participants (333 females, mean age of 62.5 years) who were at least 20 years old, including 179 participants who were previously diagnosed with hypertension. Mean AOBPs were 131.8 ± 20.9/76.6 ± 11.7 mm Hg, and CBPs were 135.6 ± 21.6/77.3 ± 11.5 mm Hg. There was a difference of 3.9 mm Hg in systolic blood pressure (SBP) and 0.8 mm Hg in diastolic BP between AOBP and CBP. In all participants, SBP and pulse pressure, as well as the white coat effect (WCE), increased with age. The cutoff value used was 140/90 mm Hg for CBP and 135/85 mm Hg for AOBP, and the prevalence of WCE and masked hypertension effect (MHE) was 12.4% and 14.1%, respectively. Even in a health checkup environment of the general population, there was a difference between the AOBP and CBP, and the WCE was observed more strongly in the elderly with a history of hypertension, suggesting that a combination of AOBP with CBP may be useful in detecting WCE and MHE in all clinical scenarios including health checkups, and help solve the “hypertension paradox” not only in Japan but in all over the world.     

Detection of masked hypertension by home blood pressure measurement: is the number of measurements an important issue?

BACKGROUND: Office blood pressure (OBP) and home blood pressure (HBP) enable the identification of patients with masked hypertension. Masked hypertension is defined by normal OBP and high HBP and is known as a pejorative cardiovascular risk factor. OBJECTIVE: The objective was to evaluate in the SHEAF study the influence of the number of office or home blood pressure measurements on the classification of patients as masked hypertensives. METHODS: Patients with OBP <140/90 mmHg (mean of six values: three measurements at two separate visits, V1 and V2) and HBP >135/85 mmHg (mean of all valid measurements performed over a 4-day period) were the masked hypertensive reference group. The consistency of the classification was evaluated by using five definitions of HBP values (mean of the 3, 6, 9, 12 and 15 first measurements) and two definitions of OBP values (mean of three measurements at V1 and mean of three measurements at V2). RESULTS: Among the 4939 treated hypertensives included in the SHEAF study, 463 (9.4%) were classified as masked hypertensives (reference group). By decreasing the number of office or home measurements, the prevalence of masked hypertension ranged from 8.9-12.1%. The sensitivity of the classification ranged from 94-69% therefore 6-31% of the masked hypertensives were not detected. The specificity ranged from 98-94% therefore 1-6% of patients were wrongly classified as masked hypertensives. CONCLUSION: A limited number of home and office BP measurements allowed the detection of masked hypertension with a high specificity and a low sensitivity. A sufficient number of measurements (three measurements at two visits for OBP and three measurements in the morning and in the evening over 2 days for HBP) are required to diagnose masked hypertension.     

Comparability of Automated Office Blood Pressure to Daytime 24-Hour Ambulatory Blood Pressure

Background

Clinical practice guidelines endorse automated office blood pressure (AOBP) measurement as the preferred in-office measurement modality. However, recent data indicate that this method may underestimate daytime ambulatory BP. The objective of this study was to further assess the comparability of mean AOBP and daytime ambulatory BP in clinical practice.

Comparative assessment of four blood pressure measurement methods in hypertensives

Introduction

Discordance between blood pressure (BP) measurement methods can occur and create ambiguity. New automated office BP monitors (AOBPs) are widely available, but their role is presently unclear. The objectives of this study are to quantify concordance among BP measurement methods and to define the diagnostic sensitivity, specificity, and predictive value of AOBPs in a population of hypertensive patients.

Methods

The office mercury sphygmomanometer, the AOBP, an ambulatory BP monitor (ABPM), and home self-measurement with an automatic device were compared in a randomized, crossover study. BP averages and achievement of therapeutic goals were defined. Comparisons and agreement tests were performed. Diagnostic indices were calculated for the AOBP.

Results

A total of 101 patients were enrolled. Average BP results were similar between measurement methods with the exception of daytime ABPM, which was significantly higher; figures are mean ± standard deviation (SD): sphygmomanometer, 129.9 ± 13.7/80.9 ± 9.3 mm Hg; AOBP, 128.4 ± 13.9/80.0 ± 9.4 mm Hg; 24-hour ABPM, 131.4 ± 11.7/78.7 ± 9.7 mm Hg; day ABPM, 135.5 ± 11.4/82.0 ± 11.9 mm Hg; home self-measurement, 131.0 ± 14.3/82.5 ± 8.2 mm Hg. Discordance in the achievement of therapeutic goals was observed in 58 patients, with only 26 cases being explained by masked hypertension or “white coat syndrome” according to all measurements. Disagreement was greater when office methods were compared with ambulatory methods.

Conclusions

This study shows that the 4 measurement strategies provide similar average BP estimates but generate many discordant results. The AOBP device can be very valuable as a replacement for the sphygmomanometer.     

Unmasking hypertension in children and adolescents with sickle/beta‐thalassemia

Sickle cell disease (SCD) is associated with increased risk of cardiovascular disease, although blood pressure (BP) levels have been reported to be lower in SCD patients compared to general population. Aims of the present study were to investigate the prevalence of BP phenotypes and levels of arterial stiffness in pediatric patients with SCD and to assess the differences with children at risk for hypertension. We included in the study 16 pediatric SCD (HbS/β‐thalassemia, S/β‐thal) patients and 16 consecutive children at risk for hypertension referred to our hypertension clinic that served as high‐risk controls. All patients underwent ambulatory BP monitoring and measurement of carotid‐femoral pulse wave velocity (PWV). S/β‐thal patients had lower office systolic BP than the high‐risk control group (115.43 ± 10.03 vs 123.37 ± 11.92, P = .05) but presented similar levels of day and night ambulatory BP. Office hypertension was found in 12.5% of the S/β‐thal patients and in 43.8% of the high‐risk controls (P = .06), while 18.8% of the S/β‐thal patients and 25% of the high‐risk controls presented hypertension by ambulatory BP levels (P = .21). All of the S/β‐thal patients with ambulatory hypertension had night hypertension (one combined night and day hypertension) with office normotension (masked hypertension). S/β‐thal patients and high‐risk controls presented equal prevalence of masked hypertension (18.8%). Children and adolescents with S/β‐thal present similar prevalence of BP phenotypes and levels of PWV with children at risk for hypertension. A significant number of children and adolescents with S/β‐thal may have masked nighttime hypertension despite normal office BP levels.     

Target organ damage in "white coat hypertension" and "masked hypertension"

BACKGROUND: In this study we investigated (i) the prevalence of white coat hypertension (WCH) and masked hypertension (MH) in patients who had never been treated earlier with antihypertensive medication, and (ii) the association of these conditions with target organ damage. METHODS: A total of 1,535 consecutive patients underwent office blood pressure (BP) measurements, 24-h ambulatory BP monitoring (ABPM), echocardiography, and ultrasonography of the carotid arteries. Subjects who showed normotension or hypertension on the basis of both office and ambulatory BP (ABP) measurement were characterized as having confirmed normotension or confirmed hypertension, respectively. WCH was defined as office hypertension with ambulatory normotension, and MH as office normotension with ambulatory hypertension. RESULTS: WCH was found in 17.9% and MH in 14.5% of the subjects. The prevalence of WCH was significantly higher in subjects with obesity, while the prevalence of MH was significantly higher in normal-weight subjects. The confirmed hypertensive subjects as well as the masked hypertensive subjects had significantly higher left ventricular mass (LVM) (corrected for body surface area) and carotid intima media thickness (cIMT) than the confirmed normotensive subjects did (108.9 +/- 30.6, 107.1 +/- 29.1 vs. 101.4 +/- 29.9 g/m(2) and 0.68 +/- 0.16, 0.68 +/- 0.21 vs. 0.63 +/- 0.15 mm, respectively, P < 0.005). White coat hypertensive subjects did not have a significantly higher LVM index than confirmed normotensive subjects (101.5 +/- 25.9 vs. 101.4 +/- 29.9 g/m(2)); they tended to have higher cIMT than the confirmed normotensive subjects, but the difference was not statistically significant (0.67 +/- 0.15 vs. 0.63 +/- 0.15 mm). CONCLUSIONS: WCH and MH are common conditions in patients who visit hypertension outpatient clinics. Confirmed hypertension and MH are accompanied by increased LVM index and cIMT, even after adjusting for other risk factors.     

The impact of the degree of obesity on the discrepancies between office and ambulatory blood pressure values in youth

OBJECTIVES: Obesity is an increasingly frequent problem among children and adolescents, and may lead to blood pressure (BP) increase. The aim of the present study was to assess the prevalence of hypertension, white-coat and masked hypertension in obese adolescents making systematic use of both office BP and 24-h ambulatory BP measurement. The impact of different degrees of obesity on BP and heart rate variability was also investigated. METHODS: Office and ambulatory BP were obtained in 285 overweight and obese Caucasian adolescents (11-18 years old) and in 180 age- and sex-matched controls. The extent of obesity was quantified using body mass index z score. RESULTS: A significant positive relationship between body mass index z score and both office and ambulatory systolic BP was found after adjusting for age and height in both boys and girls. Obese youths had not only higher BP levels, but also higher BP variability compared with controls. Among obese youths, 20.8% had abnormal BP conditions, 6.6% were white-coat hypertensives, 9.2% were masked hypertensives and 5% were sustained hypertensives. CONCLUSIONS: The prevalence of these abnormal BP conditions, which can be identified thanks to ambulatory BP monitoring, further emphasizes the usefulness of this diagnostic tool in obese youths.     

Why use automated office blood pressure measurements in clinical practice?

Automated office blood pressure (AOBP) measurement with the patient resting alone in a quiet examining room can eliminate the white-coat effect associated with conventional readings taken by manual sphygmomanometer. The key to reducing the white-coat response appears to be multiple blood pressure (BP) readings taken in a non-observer office setting, thus eliminating any interaction that could provoke an office-induced increase in BP. Furthermore, AOBP readings have shown a higher correlation with the mean awake ambulatory BP compared with BP readings recorded in routine clinical practice. Although there is a paucity of studies connecting AOBP with organ damage, AOBP values were recently found to be equally associated with left ventricular mass index as those of ambulatory BP. This concludes that in contrast to routine manual office BP, AOBP readings compare favourably with 24-hour ambulatory BP measurements in the appraisal of cardiac remodelling and, as such, could be complementary to ambulatory readings in a way similar to home BP measurements.     

Isolated uncontrolled hypertension at home and in the office among treated hypertensive patients from the J-HOME study

OBJECTIVES: To evaluate the current status of blood pressure (BP) control as measured at home and in the office, as well as to clarify and compare the prevalence and characteristics of isolated uncontrolled hypertension as measured at home (home hypertension) and in the office (office hypertension). DESIGN: A cross-sectional study. SETTING: Primary care offices in Japan. PARTICIPANTS: A sample of 3400 patients with essential hypertension (mean age, 66 years; males, 45%) receiving antihypertensive treatment. RESULTS: Overall, the mean home systolic BP (SBP)/diastolic BP (DBP) was 140/82 mmHg, and the mean office SBP/DBP was 143/81 mmHg. Of the 3400 subjects, 19% had controlled hypertension (home SBP/DBP < 135/85 mmHg and office SBP/DBP < 140/90 mmHg), 23% had isolated uncontrolled home hypertension (home SBP/DBP >/= 135/85 mmHg and office SBP/DBP < 140/90 mmHg), 15% had isolated uncontrolled office hypertension (home SBP/DBP < 135/85 mmHg and office SBP/DBP < 140/90 mmHg), and 43% had uncontrolled hypertension (home SBP/DBP >/= 135/85 mmHg and office SBP/DBP >/= 140/90 mmHg). Compared to controlled hypertension, factors associated with isolated uncontrolled home hypertension included obesity, relatively higher office SBP, habitual drinking, and the use of two or more prescribed antihypertensive drugs. Compared to uncontrolled hypertension, factors associated with isolated uncontrolled office hypertension included female gender, lower body mass index, and relatively lower office SBP. CONCLUSIONS: The use of all four, three of four, or all three predictive factors might be useful for the clinician to suspect isolated uncontrolled home or office hypertension.