New algorithm for the diagnosis of hypertension

Most national and international guidelines for diagnosing hypertension include 24-h ambulatory blood pressure monitoring (ABPM) and self (home) BP monitoring (SBPM) as optional methods for identifying hypertensive patients. However, none of the current guidelines have yet included ABPM or SBPM as fundamental tools for diagnosing hypertension, preferring instead to rely on conventional office readings recorded by mercury sphygmomanometry. During the past 10 years, clinical outcome studies have consistently reported 24-h ABPM and SBPM to be significantly better predictors of cardiovascular events compared with the office BP, even when recorded under "research conditions." Based on the available evidence, the Canadian Hypertension Education Program has now developed an algorithm for diagnosing hypertension that offers three options: 1) conventional office BP, 2) SBPM, or 3) 24-h ABPM. Out-of-office BP measurements are recommended, whenever feasible, to minimize both measurement error associated with mercury sphygmomanometry and the white coat effect experienced by some patients.     

Future developments in ambulatory blood pressure monitoring and self-blood pressure monitoring in clinical practice

A number of factors interact to promote the increased clinical use of both ambulatory blood pressure monitoring (ABPM) and self-blood pressure monitoring (SBPM). These include the phasing out of mercury, evidence of the unreliability of clinic measurements, technical advances in automated blood pressure measurement, increasing evidence that out-of-office measurements give the best risk assessment, and a gradual recognition by payers of the clinical utility of ABPM and SBPM. Both ABPM and SBPM have been endorsed by the two major guidelines for managing hypertensive patients (World Health Organization-International Society of Hypertension and Joint National Committee VI). The use of SBPM has grown enormously over the past few years, mostly because of direct sales to patients. Although SBPM may give a better estimate of the true blood pressure than clinic readings, there are concerns about the accuracy of the monitors in individual patients. The main clinical indication for ABPM is the diagnosis of white-coat hypertension. This requires the demonstration that the blood pressure is normal outside the clinic, which can be established using SBPM and confirmed by ABPM. Even though ABPM may save drug costs in patients with white-coat hypertension, its use may also lead to increased drug expenditure in others in whom it demonstrates suboptimal blood pressure control. SBPM has the potential to reduce the number of clinic visits and also to improve blood pressure control. The ultimate validation of both procedures will be whether they can prevent cardiovascular morbidity. There have been suggestions that a non-dipping pattern of nocturnal blood pressure may carry a bad prognosis, but this may apply only to certain disease end-points. The greater recognition of the relevance of dipping status should provide an additional stimulus to the growth of both procedures. It is anticipated that, in the future, hypertension will be managed by the 'virtual hypertension clinic', using ABPM for the initial diagnosis, and SBPM with electronic linkage between the patient and the health-care provider for maintenance and follow-up.     

Usefulness of ambulatory blood pressure monitoring in diagnosis of arterial hypertension in children and adolescents

BACKGROUND: Arterial hypertension in children and adolescents is an important medical problem with a prevalence rising over the last ten years from 1 to 4.5%. AIM: To assess the usefulness of ambulatory blood pressure monitoring (ABPM) in diagnosis of arterial hypertension in children and adolescents. METHODS: Two hundred and twelve children with elevated blood pressure (BP) and 81 healthy controls participated in this study. In all children from the study and control groups standard BP measurement and ABPM were performed. RESULTS: With the use of standard BP measurement, 168 (79.2%) children were diagnosed as hypertensive and the remaining 44 (20.8%) as prehypertensive. When the ABPM was used, arterial hypertension was diagnosed in 143 (67.4%) cases and white coat hypertension in the remaining 69 (32.6%) subjects. In 7 (8.7%) control children elevated BP in ABPM was detected, and masked hypertension were diagnosed. CONCLUSIONS: 1. Ambulatory blood pressure monitoring is a useful tool in diagnosis of arterial hypertension in children and adolescents. 2. Systolic hypertension is a major form of hypertension in childhood. 3. Ambulatory blood pressure monitoring is helpful to identify patients with white coat hypertension. 4. Further studies are necessary to establish uniform indications, standards and rules for interpretation of ABPM in children and adolescents.     

Assessment of self-monitoring of blood pressure in the diagnosis of isolated clinic hypertension

BACKGROUND: There are no studies assessing cardiovascular morbidity, morality in patients with isolated clinical hypertension (ICH) with self-blood pressure monitoring (SBPM). OBJECTIVES: To determine the value of SBPM in the diagnosis of ICH. METHODS: Cohort study. New hypertensive and normotensive patients 15-75 years, without cardiovascular events history. VARIABLES: Oriented anamnesis hypertension; blood pressure measurements (BP): clinical BP, SBPM and ambulatory BP monitoring (ABPM); evaluation of target organ damage (TOD); electrocardiogram; retinography and microalbuminuria (MA). RESULTS: One hundred and thirty-five patients, 95 hypertensive (62.1% males; mean age 59.08+/-16.8 years), 40 normotensive (37.5% males; mean are 56.32+/-10.22 years). BP measurements (mmHG) in normotensives vs hypertensives: clinical BP, 125.36/76.74 vs 149.81/87.86 mmHg (p<0.0001) and SPPM, 114.90/69.96 vs 142.06/86.31 (p<0.0001). Twenty-four-hour ABPM: 135.41/81/81.74. Prevalence of TOD in hypertensive: 23.10% left ventricular hypertrophy (LVH), sustained hypertension (SH): clinic BP, 149.88/86.34 vs 152.51/89.55 (p>0.10); SBPM: 147.895/88.95 vs 128.17/79 (p<0.0001) and ABPM, 141.72/88.22 vs 131.66/80 (p=0.053 for systolic). TOD in SH vs ICH: LVH, 24.6% vs 19.2% (p=0.814); exudates or haemorrhages, 7.7% vs 9.8% (p=0.580). The risk of an occurrence of any TOD in ICH patients is lower for 125/80 (OR=2.5). CONCLUSIONS: VAMPAHICA will provide information about value SBPM in the diagnosis of ICH. Advanced retinopathy is relative frequent in ICH patients. If TOD is accepted as a surrogate endpoint, the diagnostic values of ICH will be probably decreased.     

Primary arterial hypertension. 24-hour recording or casual blood pressure measurement?]

In 134 patients with essential hypertension 24-hour blood pressure ambulatory monitoring (ABPM) as well as traditional blood pressure measurements (casual BP) were performed. Maximal and mean whole-day systolic and diastolic blood pressure values in ABPM were compared with casual BP (using test t). The casual BP was also compared with mean systolic and diastolic blood pressure values calculated separately in three eight-hours periods of day. Maximal BP values in ABPM were significantly higher and mean significantly lower than casual BP values. Blood pressure registered during work hours was closest to casual BP values. Blood pressure in the evening was similar to whole-day blood pressure mean. The results indicate, that automatic blood pressure monitoring performed in this period of day has the greatest diagnostic value because it could be free from "white coat hypertension" syndrome.     

Diagnosis of white coat hypertension by ambulatory blood pressure monitoring.

White coat hypertension (WCH) is common in referred hypertensive patients. Ambulatory blood pressure monitoring (ABPM) is not free from the white coat syndrome. We examined the use of the elevation of the first and last measurements of ABPM for diagnosis of WCH in a hypertensive population that had been referred to a hospital-based hypertension unit. Data were obtained on 1350 patients for clinic and ABPM parameters. WCH, as diagnosed by conventional clinic blood pressure (BP) measurement, was compared with a variety of alternative methods determined from ABPM. In all cases, mean daytime pressure was <135 mm Hg/85 mm Hg with an elevation of clinic BP >/=140 mm Hg systolic or 90 mm Hg diastolic. The definitions tested for this elevation were first hour mean pressure, first reading, maximum reading in first hour, last hour mean pressure, last reading, maximum reading in the last hour and maximum reading in first or last hour. Elevation of the maximum pressure in the first hour or last hour above 140 mm Hg systolic or 90 mm Hg diastolic showed a high level of agreement (kappa=0.91) with classical WCH for diagnosis of the white coat syndrome. Termed ambulatory white coat hypertension, patients with this finding were older than classic white coat patients and had higher daytime (127+/-6/78+/-5 mm Hg versus 121+/-5.5/74+/-6 mm Hg, P<0.005 for systolic and diastolic) and nighttime (114+/-11/67+/-8 mm Hg versus 106+/-9/61+/-6 mm Hg, P<0.005 for systolic and diastolic) pressures. They also had a significantly greater Sokolow-Lyon index (leads V(1)+V(5), 21+/-7 mV versus 18+/-6 mV). Elevation of BP above 140 mm Hg systolic or 90 mm Hg diastolic in the first or last hour of monitoring diagnoses patients with a white coat response in whom there is a higher BP profile than in patients with classic white coat response alone. We suggest, therefore, that this is a better measure of the white coat phenomenon.     

Using out of office blood pressure monitoring in the management of hypertension

Self-measurement of blood pressure (BP) and 24-hour ambulatory BP monitoring (ABPM) are increasingly used in order to improve cardiovascular risk stratification over and beyond traditional methods, including sphygmomanometric BP measurement. Self-measured BP has the advantage of being cheap, quite representative of the usual BP over long periods of time, and devoid of the "white coat" effect. Only a few data exist on the prognostic value of self-measured BP. Most of the outcome studies with 24-hour ABPM have been conducted in patients with essential hypertension who were untreated at the time of execution of ABPM. Cardiovascular risk showed a direct association with ambulatory BP and an inverse association with the degree of BP reduction from day to night. White coat hypertension versus ambulatory hypertension and dippers versus nondippers are two classifications based on arbitrary operational risk categories. ABPM may be valuable for refining cardiovascular risk stratification in untreated subjects with office hypertension, as well as those with resistant hypertension.     

Ambulatory and self-monitoring of blood pressure: coming of age

Conclusions Both ABPM and SBPM seem to be useful tools to employ in clinical practice. They may help in identifying patients who are at lower risk, and in monitoring the effects of treatment. Although the cost-effectiveness of these methods is still being scrutinized, it is to be expected that SBPM, and to a lesser degree ABPM, will in the long run prove to reduce costs of hypertension treatment.     

Current status of ambulatory blood pressure monitoring in Asian countries: A report from the HOPE Asia Network

Ambulatory blood pressure monitoring (ABPM) can measure 24‐hour blood pressure (BP), including nocturnal BP and diurnal variations. This feature of ABPM could be of value in Asian populations for preventing cardiovascular events. However, no study has yet investigated regarding the use of ABPM in actual clinical settings in Asian countries/regions. In this study, 11 experts from 11 countries/regions were asked to answer questionnaires regarding the use of ABPM. We found that its use was very limited in primary care settings and almost exclusively available in referral settings. The indications of ABPM in actual clinical settings were largely similar to those of home BP monitoring (HBPM), that is, diagnosis of white‐coat or masked hypertension and more accurate BP measurement for borderline clinic BP. Other interesting indications, such as nighttime BP patterns, including non‐dipper BP, morning BP surge, and BP variability, were hardly adopted in daily clinical practice. The use of ABPM as treatment guidance for detecting treated but uncontrolled hypertension in the Asian countries/regions didn't seem to be common. The barrier to the use of ABPM was primarily its availability; in referral centers, patient reluctance owing to discomfort or sleep disturbance was the most frequent barrier. ABPM use was significantly more economical when it was reimbursed by public insurance. To facilitate ABPM use, more simplified indications and protocols to minimize discomfort should be sought. For the time being, HBPM could be a reasonable alternative.     

The use of ambulatory blood pressure monitoring among Medicare beneficiaries in 2007–2010

The US Centers for Medicaid and Medicare Services reimburses ambulatory blood pressure monitoring (ABPM) for suspected white coat hypertension. We estimated ABPM use between 2007 and 2010 among a 5% random sample of Medicare beneficiaries (≥65 years). In 2007, 2008, 2009, and 2010, the percentage of beneficiaries with ABPM claims was 0.10%, 0.11%, 0.10%, and 0.09%, respectively. A prior diagnosis of hypertension was more common among those with versus without an ABPM claim (77.7% vs. 47.0%). Among hypertensive beneficiaries, 95.2% of those with an ABPM claim were taking antihypertensive medication. Age 75–84 versus 65–74 years, having coronary heart disease, having chronic kidney disease, having multiple prior hypertension diagnoses, and having filled multiple classes of antihypertensive medication were associated with an increased odds for an ABPM claim among hypertensive beneficiaries. ABPM use was very low among Medicare beneficiaries and was not primarily used for diagnosing white coat hypertension in untreated individuals.     

Ambulatory blood pressure monitoring: practical considerations

Ambulatory blood pressure monitoring (ABPM) allows one to evaluate the blood pressure (BP) profile over a 24-hour period in the patient's natural environment. Casual pressure measurements in the physician's office can be affected by alarm reactions, thus causing "white coat" hypertension. ABPM allows one to evaluate these reactions and determine the average pressure and variability of BP along with the effects of physical activity and emotional arousal on BP patterns while at work, at home, and during sleep. Average pressures determined by ABPM are more predictive of target organ involvement and cardiovascular complications of hypertension than casual monitoring of BP in the clinic. The absence of physiologic decline in arterial pressure during sleep is associated with increased prevalence of atherosclerotic complications and left ventricular hypertrophy as well as impairment of the autonomic nervous system. Although further prospective studies are needed to confirm the benefits of home pressure readings and ABPM, ABPM can be helpful in the diagnosis and determination of prognosis and therapeutic responses in a select group of patients.     

Prevalence of the white-coat effect at multiple visits before and during treatment

OBJECTIVE: To investigate the prevalence and persistence of the white-coat effect (WCE) and white-coat hypertension (WCH) on multiple blood pressure measurement occasions in hypertensive patients with and without treatment. DESIGN: Essential hypertensive patients in whom we took office blood pressure measurements (OBPM) at eight visits (three readings per visit) performed self blood pressure measurements (SBPM) for 1 week prior to each visit (42 readings per week) over a period of 1 year. All measurements were performed with the same automatic device (Omron 705CP). In addition, 24-h ambulatory blood pressure monitoring (ABPM) was performed at the start and at the end of the study. At the start, patients did not use any medication but on subsequent visits they were treated on the basis of their SBPM values. WCH was defined as an OBPM-value > or = 140 and/or 90 mmHg and a SBPM or daytime ABPM value < 135/85 mmHg. This definition was used irrespective of treatment. We also determined the prevalence of a substantial WCE (OBPM 20 mmHg systolic or 10 mmHg diastolic higher than SBPM or daytime ABPM). SETTING: Patients were recruited at hospital or general practice. PATIENTS: A total of 163 mild-to-moderate essential hypertensive patients with a mean age of 56 years (56% males). RESULTS: At eight blood pressure (BP) measurement occasions, 75% of all patients had a substantial WCE at least once, while 57% had WCH at least once. One-third of the patients consistently had a substantial WCE and 14% consistently had WCH on three or more occasions The magnitude of the WCE was significantly related to the height of blood pressure in treated but not in untreated patients. CONCLUSION: In some patients, WCH or a substantial WCE occurs consistently on multiple OBPM visits. Especially in untreated patients, the magnitude of the WCE varies widely among individuals. These results support the incorporation of SBPM and/or ABPM into optimal management of hypertension, not only to prevent misdiagnosis in untreated patients but also to determine the need for adjusting antihypertensive therapy in treated subjects.     

Ambulatory Blood Pressure Monitoring and Echocardiographic Findings in Renal Transplant Recipients

Hypertension is common in renal transplant recipients (RTRs). Ambulatory blood pressure (BP) monitoring (ABPM) is important in diagnosing hypertension and diurnal BP variation. The authors set out to compare office BP and ABPM measurements to determine diurnal pattern and to evaluate echocardiographic findings in RTRs. ABPM and office BP measurements were compared in 87 RTRs. Echocardiographic evaluation was performed for each patient. The correlations between office and 24‐hour ABPM were 0.275 for mean systolic BP (P=.011) and 0.260 for mean diastolic BP (P=.017). Only 36.8% had concordant hypertension between office BP and ABPM, with a masked hypertension rate of 16.1% and white‐coat effect rate of 24.1%. Circadian BP patterns showed a higher proportion of nondippers (67.8%). Left ventricular mass index was increased in 21.8% of all recipients. There was a significant but weak correlation between office BP and ABPM.     

Ambulatory blood pressure monitoring to study white coat syndrome in patients with hypertension seen in primary care

INTRODUCTION AND OBJECTIVES: The white coat phenomenon is said to occur when the difference between systolic/diastolic blood pressure measured during visits to the doctor's office and in ambulatory recordings is greater than 20/10. These absolute differences, known as the white coat effect, may lead to normotensive patients being classified as having white coat hypertension (WCH). We used ambulatory blood pressure monitoring (ABPM) to monitor the prevalence and response (white coat effect, white coat hypertension or white coat phenomenon) in patients during pharmacological treatment for grade 1 or 2 hypertension, and 4 weeks after treatment was suspended under medical supervision. PATIENTS AND METHOD: Ambulatory blood pressure monitoring was used in 70 patients with hypertension that was well controlled with treatment. Blood pressure was recorded during treatment (phase 1) and 4 weeks after treatment was stopped (phase 2). RESULTS: 18 (26%) of the 70 patients did not participate in phase 2 because when medication was withdrawn, their blood pressure values became unacceptable and it was necessary to restart treatment. The white coat effect was significantly stronger in phase 1, and the prevalence of white coat phenomenon and white coat hypertension did not differ significantly between phases. At the end of phase 2 the prevalence of white coat hypertension was 33%. CONCLUSIONS: Withdrawal of antihypertensive medication in patients with well controlled grade 1 or grade 2 hypertension did not significantly modify the prevalence of white coat phenomenon or white coat hypertension. The white coat effect was greater while patients were on pharmacological treatment. One third of our patients were considered to have been mistakenly diagnosed as having hypertension.     

White Coat Effect and Its Clinical Implications in the Elderly

The aim of this study was to investigate the frequency and correlated factors of white coat effect (WCE) in the elderly. Geriatric patients who were known as normotensive and office BP exceeding 140/90 mmHg underwent 24-hour ambulatory blood pressure monitoring (ABPM). Correlation of WCE with clinical parameters, geriatric assessment scales, co-existing diseases, and laboratory results were analyzed. Within 61 patients 72.1% were diagnosed as white coat hypertension (WCH). Independent correlates of systolic WCE were activities of daily living, instrumental activities of daily living scores, creatinine; independent correlate of diastolic WCE was Geriatric Depression Scale score. White coat hypertension constitutes a major part of office-detected hypertension in geriatric patients. Ambulatory blood pressure monitoring should be performed on geriatric patients with office-measured hypertension in order to avoid overtreatment.     

Ambulatory vs Office Blood Pressure Monitoring in Renal Transplant Recipients

Hypertension is common following renal transplantation and has adverse effects on cardiovascular and graft health. Ambulatory blood pressure monitoring (ABPM) is better at overall blood pressure (BP) assessment and is necessary to diagnose nocturnal hypertension, which is also implicated in poor outcomes. The authors performed a retrospective analysis of 98 renal transplant recipients (RTRs) and compared office BP and ambulatory BP recordings. ABPM revealed discordance between office BP and ambulatory BP in 61% of patients, with 3% caused by white‐coat and 58% caused by masked hypertension (of which 33% were caused by isolated nocturnal hypertension). Overall, mean systolic BP was 3.6 mm Hg (0.5–6.5) and diastolic BP was 7.5 mm Hg (5.7–9.3) higher via ambulatory BP than office BP. This was independent of estimated glomerular filtration rate, proteinuria, transplant time/type, and comorbidities. A total of 42% of patients had their management changed after results from ABPM. ABPM should be routinely offered as part of hypertension management in RTRs.     

Should we use ambulatory blood pressure monitoring to guide therapy?

Blood pressure (BP) measured exclusively in the office setting is no longer acceptable as a sole criterion for diagnosing and treating hypertension. Out-of-office measurements are needed. The limitations of office measurements are principally the result of the small number of readings and the white coat effect. Ambulatory BP monitoring (ABPM) is the gold standard for assessing an individual patient’s risk and hence the need for treatment. Patients who have a high nocturnal BP (nondippers) may be at high risk, and the dipping pattern may be normalized by drug treatment. In addition, it is important to assess that treatment is lowering BP for the full 24 hours (peak and trough effects). However, ABPM is not well suited to the repeated assessments that are needed for the evaluation of the response to treatment. For this, home monitoring is preferred and, by using morning and evening measurements, the effects of treatment on the trough and peak BP can be determined.     

Ambulatory blood pressure monitoring

Ambulatory blood pressure monitoring (ABPM) is becoming widely accepted as a clinically useful tool for assessing cardiovascular risk in hypertensive patients, although it is not generally recognized for reimbursement in the United States. There are now six major prospective studies, all of which have shown that ABPM gives a better prediction of risk than conventional clinic measurement. A corollary of these findings is that patients with white coat hypertension have been found to be at relatively low risk. The major clinical indications include patients with newly diagnosed hypertension, suspected white coat hypertension, and refractory hypertension. White coat hypertension is common during pregnancy and may lead to unnecessary cesarean sections.     

Ambulatory blood pressure monitoring

Ambulatory blood pressure monitoring (ABPM) is becoming widely accepted as a clinically useful tool for assessing cardiovascular risk in hypertensive patients, although it is not generally recognized for reimbursement in the United States. There are now six major prospective studies, all of which have shown that ABPM gives a better prediction of risk than conventional clinic measurement. A corollary of these findings is that patients with white coat hypertension have been found to be at relatively low risk. The major clinical indications include patients with newly diagnosed hypertension, suspected white coat hypertension, and refractory hypertension. White coat hypertension is common during pregnancy and may lead to unnecessary cesarean sections.     

Ambulatory Blood Pressure Monitoring to Assess the White‐Coat Effect in an Elderly East African Population

The authors hypothesized that published hypertension rates in Tanzania were influenced by the physiological response of individuals to blood pressure (BP) testing, known as the white‐coat effect (WCE). To test this, a representative sample of 79 participants from a baseline cohort of 2322 people aged 70 years and older were followed to assess BP using conventional BP measurement (CBPM) and ambulatory BP monitoring (ABPM). There was a significant difference between daytime ABPM and CBPM for both systolic BP (mean difference 29.7 mm Hg) and diastolic BP (mean difference 7.4 mm Hg). Rates of hypertension were significantly lower when measured by 24‐hour ABPM (55.7%) than by CBPM (78.4%). The WCE was observed in 54 participants (68.4%). The WCE was responsible for an increase in recorded BP. Accurate identification of individuals in need of antihypertensive medication is important if resources are to be used efficiently, especially in resource‐poor settings.