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

Automated office blood pressure (AOBP) measurement, attended or unattended, eliminates the white coat effect (WCE) showing a strong association with awake ambulatory blood pressure (ABP). This study examined the difference in AOBP readings, with and without 5 minutes of rest prior to three readings recorded at 1‐min intervals. Cross‐sectional data from 100 randomized selected hypertensives, 61 men and 39 women, with a mean age of 52.2 ± 10.8 years, 82% treated, were analyzed. The mean systolic AOBP values without preceding rest were 127.0 ± 18.2 mm Hg, and the mean systolic AOBP values with 5 minutes of preceding rest were 125.7 ± 17.9 mm Hg (P = .05). A significant order effect was observed for the mean systolic BP values when AOBP without 5 minutes of preceding rest was performed as the first measurement (130.0 ± 17.7 vs 126.5 ± 16.2, P = .008). When we used a target systolic AOBP ≥ 130 mm Hg, awake ABP yielded lower readings, while at a target systolic AOBP value of < 130 mm Hg higher awake ABP values were obtained. Our findings indicate that systolic AOBP can be initially checked without any preceding rest and if readings are normal can be accepted. Otherwise, when AOBP is ≥ 130 mm Hg, measurements should be rechecked with 5 minutes of rest.     

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.     

Ambulatory blood pressure phenotypes and isolated elevation of office central or brachial blood pressure

Disagreements in office brachial and central blood pressure (BP) have resulted in the identification of novel hypertension phenotypes, namely isolated central hypertension (ICH) and isolated brachial hypertension (IBH). This study investigated the relationship of ICH and IBH with ambulatory BP phenotypes among 753 individuals (mean age = 47.6 ± 15.2 years, 48% males) who underwent office and 24‐hours brachial and central BP measures using a Mobil‐O‐Graph PWA monitor. Thresholds for elevated office central and brachial BP were 130/90 and 140/90 mm Hg. Results of multivariable analysis adjusted for potential confounders showed that ICH (n = 25) had 3.71‐fold (95% CI 1.48‐9.32; P = .005) greater risk of masked hypertension than normal brachial/central BP (n = 362), while IBH (n = 20) had 4.65‐fold (95% CI 1.76‐12.25; P = .002) greater risk of white coat hypertension compared with combined brachial/central hypertension (n = 346). These findings suggest that the diagnosis of ICH and IBH might be useful in identifying individuals at higher risk of presenting discordant office and ambulatory BP phenotypes.     

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 among research,home, and office blood pressure measurements for pregnant women: The TMM BirThree Cohort Study

Blood pressure (BP) measurements of pregnant women have been collected in offices and at home for previous research. However, it remains uncertain whether there is difference between research BP, defined as BP measured for the purpose of epidemiological research and BP measured at home or in an office. Therefore, the present study aimed to compare research BP with home and unstandardized office BP. Research, home, and office BP were measured among pregnant women who participated in the Tohoku Medical Megabank Project Birth and Three‐Generation Cohort Study (TMM BirThree Cohort Study). Research BP was measured twice at our research center while the participant was seated and after resting for 1‐2 minutes. Research, home, and office BP were compared and agreement among the values was assessed. Differences among research, home, and office BP values and possible factors affecting differences were analyzed. Among 656 pregnant women, the mean (± standard deviations) research systolic (S), diastolic (D) BP, home SBP, home DBP office SBP, and office DBP were 103.8 ± 8.5, 61.8 ± 7.3, 104.4 ± 9.2, 61.2 ± 6.8, 110.5 ± 10.8, and 63.8 ± 8.7mmHg, respectively. Research SBP value was lower than home value (P = .0072; difference between mean research and home BP: −0.61 ± 7.8 mmHg). Research SBP and DBP values were lower than office values (P < .0001 for both SBP and DBP; means ± standard deviations of differences between research and office BP: 6.7 ± 10.1 and 2.0 ± 8.5 mmHg for SBP and DBP, respectively). In conclusion, when research BP is measured under conditions controlled, research BP can give close values to home BP for pregnant women.     

Home blood pressure control status in 2017‐2018 for hypertension specialist centers in Asia: Results of the Asia BP@Home study

A self‐measured home blood pressure (BP)‐guided strategy is an effective practical approach to hypertension management. The Asia BP@Home study is the first designed to investigate current home BP control status in different Asian countries/regions using standardized home BP measurements taken with the same validated home BP monitoring device with data memory. We enrolled 1443 medicated hypertensive patients from 15 Asian specialist centers in 11 countries/regions between April 2017 and March 2018. BP was relatively well controlled in 68.2% of patients using a morning home systolic BP (SBP) cutoff of <135 mm Hg, and in 55.1% of patients using a clinic SBP cutoff of <140 mm Hg. When cutoff values were changed to the 2017 AHA/ACC threshold (SBP <130 mm Hg), 53.6% of patients were well controlled for morning home SBP. Using clinic 140 mm Hg and morning home 135 mm Hg SBP thresholds, the proportion of patients with well‐controlled hypertension (46%) was higher than for uncontrolled sustained (22%), white‐coat (23%), and masked uncontrolled (9%) hypertension, with significant country/regional differences. Home BP variability in Asian countries was high, and varied by country/region. In conclusion, the Asia BP@Home study demonstrated that home BP is relatively well controlled at hypertension specialist centers in Asia. However, almost half of patients remain uncontrolled for morning BP according to new guidelines, with significant country/regional differences. Strict home BP control should be beneficial in Asian populations. The findings of this study are important to facilitate development of health policies focused on reducing cardiovascular complications in Asia.     

Early morning home blood pressure control among treated patients with controlled office blood pressure

Elevated morning blood pressure (BP) has a significantly increased risk of cardiovascular events, so morning BP is of substantial clinical importance for the management of hypertension. This study aimed to evaluate early morning BP control and its determines among treated patients with controlled office BP. From May to October 2018, 600 treated patients with office BP < 140/90 mm Hg were recruited from hypertension clinics. Morning BP was measured at home for 7 days. Morning home systolic blood pressure (SBP) increased by an average of 11.5 mm Hg and that morning home diastolic blood pressure (DBP) increased by an average of 5.6 mm Hg compared with office BP. Morning home SBP, DBP, and their moving average were more likely to be lower among patients with a office SBP < 120 mm Hg than among patients with a office SBP ranging from 120 to 129 mm Hg and from 130 to 139 mm Hg (P < .001). A total of 45% of patients had early morning BP < 135/85 mm Hg. The following factors were significantly correlated with morning BP control: male sex, age of <65 years, absence of habitual snoring, no drinking, adequate physical activity, no habit of high salt intake, office BP < 120/80 mm Hg, and combination of a calcium channel blocker (CCB) and angiotensin receptor blocker or angiotensin‐converting enzyme inhibitor (ARB/ACEI). Less than half of patients with controlled office BP had controlled morning BP and that positive changes may be related to an office BP < 120/80 mm Hg, combination of a CCB and ACEI/ARB and a series of lifestyle adjustments.     

Automated office blood pressure is in agreement with awake and mean 24‐hour ambulatory blood pressure at the lower blood pressure range

Automated office blood pressure measurement eliminates the white coat effect and is associated with awake ambulatory blood pressure. This study examined whether automated office blood pressure values at lower limits were comparable to those of awake and mean 24‐hour ambulatory blood pressure. A total of 552 patients were included in the study, involving 293 (53.1%) men and 259 (46.9%) women, with a mean age 55.0 ± 12.5, of whom 36% were treated for hypertension. Both systolic and diastolic automated office blood pressures exhibited lower values compared to awake ambulatory blood pressure among 254 individuals with systolic automated office blood pressure <130 mm Hg (119 ± 8 mm Hg vs 125 ± 11 mm Hg, P < .0001 and 75 ± 9 mm Hg vs 79 ± 9 mm Hg, P < .0001 for systolic and diastolic BPs, respectively). Furthermore, the comparison of systolic automated office blood pressure to the mean 24‐hour ambulatory blood pressure levels also showed lower values (119 ± 8 vs 121 ± 10, P = .007), whereas the diastolic automated office blood pressure measurements were similar to 24‐hour ambulatory blood pressure values. Our findings show that when automated office blood pressure readings express values <130/80 mm Hg in repeated office visits, further investigation should be performed only when masked hypertension is suspected; otherwise, higher automated office blood pressure values could be used for the diagnosis of uncontrolled hypertension, especially in individuals with organ damage.     

Differences in ambulatory blood pressure profiles between Japanese and Thai patients with hypertension /suspected hypertension

Ethnic differences in the profiles of hypertension and cardiovascular risk have been reported between Asians and Westerners. However, blood pressure (BP) profiles and the risk factors for cardiovascular disease might differ even among different Asian populations because of the diversity of cultures, foods, and environments. We retrospectively examined differences in 24‐h BP profiles between 1051 Japanese (mean age, 62.5 ± 12.4 years; medicated hypertension, 75.7%) and 804 Thai (mean age, 56.9 ± 18.5 years; medicated hypertension, 65.6%) by using the Japanese and Thai ambulatory BP monitoring (ABPM) databases, in order to check the BP control status in treated hypertensives and to inform the clinical diagnosis of hypertension. The two populations had similar office systolic BP (SBP) (142.7 ± 20.0 vs 142.3 ± 20.6 mm Hg, p = .679). However, the Japanese population had higher 24‐hr average and daytime SBP, and the Thai population had higher nighttime SBP even after adjusting for cardiovascular risk factors (all p < .05). Greater morning BP surge was observed in Japanese (31.2 vs 22.8 mm Hg, p < .001). Regarding nocturnal BP dipping status, the prevalence of riser status (higher nighttime than daytime SBP) was higher in the Thai population (30.5% vs 10.9%). These findings suggest that a substantial difference in 24‐hr BP profiles exists between even neighboring countries in Asia.     

Development and implementation of blood pressure screening and referral guidelines for German community pharmacists

Involvement of community pharmacists in the detection and control of hypertension improves patient care. However, current European or North‐American guidelines do not provide specific guidance how to implement collaboration between pharmacists and physicians, especially when and how to refer patients with undetected or uncontrolled hypertension to a physician. The German Society of Cardiology and the ABDA – Federal Union of German Associations of Pharmacists developed and tested referral recommendations for community pharmacists, embedded in two guideline worksheets. The project included a guideline‐directed blood pressure (BP) measurement and recommendations when patients should be referred to their physician. A “red flag” referral within 4 weeks was recommended when SBP was >140 mm Hg or DBP >90 mm Hg (for subjects <80 years), and >160 mm Hg or >90 mm Hg (≥80 years) in undetected individuals, or >130 mm Hg or >80 mm Hg (<65 years) and >140 mm Hg or >80 mm Hg (≥65 years) in treated patients. BP was measured in 187 individuals (86 with known hypertension, mean [±SD] age 62 ± 15 years, 64% female, and 101 without known hypertension, 47 ± 16 years, 75% female) from 17 community pharmacies. In patients with hypertension, poorly controlled BP was detected in 55% (n = 47) and were referred. A total of 16/101 subjects without a history of hypertension were referred to their physician because of uncontrolled BP. Structured BP testing in pharmacies identified a significant number of subjects with undetected/undiagnosed hypertension and patients with poorly controlled BP. Community pharmacists could play a significant role in collaboration with physicians to improve the management of hypertension.     

Pharmacological treatment of high‐normal blood pressure (prehypertension) in high‐risk patients for primary prevention of cardiovascular events

Currently, the best treatment strategy for patients with a high‐normal blood pressure (prehypertension) is not known. The authors aimed to determine whether pharmacological reduction of systolic blood pressure (SBP) to a normal level (<120 mm Hg) would prevent cardiac morbidity and mortality in prehypertensive patients. In this secondary analysis, the authors obtained the data from SPRINT from the National Heart, Lung, and Blood Institute data repository center. Among 9361 patients enrolled in SPRINT, 289 high‐risk (ASCVD risk = 24.8% ± 13.0 [10‐65]) prehypertensive patients without previous cardiovascular disease and not receiving any antihypertensive medications were enrolled. One hundred and forty‐eight of them were assigned to standard treatment which consisted of clinical follow‐up till SBP goes above 140 mm Hg and then staring medications to keep SBP <140 mm Hg. One hundred and forty‐one were assigned to the intensive treatment receiving pharmacological SBP reduction to <120 mm Hg upon enrollment. The primary composite outcome was myocardial infarction, and other acute coronary syndromes, stroke, heart failure, or death from cardiovascular causes. Throughout the 3.06 years of follow‐up, a primary outcome event was confirmed in three participants (0.74% per year) in the intensive‐treatment group and 8 (1.61% per year) in the standard‐treatment group (hazard ratio [HR], 0.19; P = .045). Rates of serious adverse events were not increased by intensive‐treatment (HR, 0.83; P = .506). Based on this secondary post hoc analysis, intensive SBP reduction may probably be beneficial for primary prevention of cardiovascular morbidity and mortality in high‐risk prehypertensive patients. This finding needs to be evaluated in a larger trial designed specifically to answer this question.     

Discrepancies in the diagnosis of hypertension in adolescents according to available office and home high blood pressure criteria

This study aimed at comparing the prevalence of abnormal blood pressure (BP) phenotypes among 241 adolescents referred for hypertension (15.4 ± 1.4 years, 62% males, 40% obese) according to mostly used or available criteria for hypertension [AAP or ESH criteria for high office BP (OBP); Arsakeion or Goiânia schools’ criteria for high home BP monitoring (HBPM)]. High OBP prevalence was greater when defined by AAP compared with ESH criteria (43.5% vs. 24.5%; p < .001), while high HBPM prevalence was similar between Arsakeion and Goiânia criteria (33.5% and 37.5%; p = .34). Fifty‐five percent of the sample fulfilled at least one criterion for high BP, but only 31% of this subsample accomplished all four criteria. Regardless of the HBPM criteria, AAP thresholds were associated with lower prevalence of normotension and masked hypertension and greater prevalence of white‐coat and sustained hypertension than ESH thresholds. These findings support the need to standardize the definition of hypertension among adolescents.     

Attended vs unattended systolic blood pressure measurement: A randomized comparison in patients with cardiovascular disease

Recent clinical guidelines recommend lower blood pressure (BP) goals for most patients, and recent trends have favored use of automated unattended BP measurements in the office setting to minimize observer error and white‐coat effects. Patients attending a routinely scheduled CVD clinic visit were prospectively randomized to BP measured using an attended, followed by an unattended method, or vice versa, after a controlled rest period. All study BP measurements were obtained in triplicate using the automated Omron HEM‐907XL BP monitor, and averaged. The outcome was difference in SBP. Routinely measured clinic BP from the same visit was extracted from the medical record, and compared with attended and unattended BP. A total of 102 patients were randomized, and mean age was 63 years, 52% female and 75% Caucasian. Attended and unattended SBP was 125.4 ± 20.4 and 122.6 ± 21.0 mm Hg, mean ± SD, respectively. Routine clinic SBP was 130.6 ± 23.6 mm Hg. Attended SBP was 2.7 mm Hg higher than the unattended measurement (95% CI 1.3‐4.1; P = .0002). Routine clinic SBP was 5.2 mm Hg higher than attended SBP (95% CI 2.4‐8.0; P = .0003) and 8.0 mm Hg higher than unattended SBP (95% CI 5.4‐10.5; P < .0001). Attended measurement of BP is significantly higher than unattended measurement and the difference is physiologically meaningful, even in a CVD cohort with generally well‐controlled hypertension. Furthermore, routine clinic SBP substantially overestimates both attended and unattended automated SBP, with important implications for treatment decisions like dose and/or drug escalation.     

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.     

Nocturnal hypertension in primary care patients with high office blood pressure: A regional study of the MAPAGE project

Nocturnal hypertension (NH) is an independent cardiovascular risk factor. We aimed to describe the frequency of NH among primary care hypertensive patients and to analyze NH determinants. This observational, cross‐sectional, multicenter study enrolled the patients of 23 general practitioners in Burgundy region, France. We included the first patient of the day with office blood pressure ≥ 140/90 mm Hg, whatever the reason for consultation. All included patients had 24‐hour ambulatory blood pressure monitoring (ABPM). Nocturnal hypertension was considered nighttime mean blood pressure ≥ 120/70 mm Hg, as per current guidelines. Medical, sociodemographic, and deprivation data were collected. Nocturnal hypertensive and non‐hypertensive patients were compared. The determinants of NH were identified using logistic regression models. From July 2015 to November 2018, 447 patients were analyzed. Mean office blood pressure was 158.6/91.5 mm Hg, and 255 patients (57.0%) were taking at least one antihypertensive drug. Among the 409 (91.5%) valid ABPM, 316 (77.3%) showed NH. In multivariate analyses, male sex (odds ratio [OR] = 2.20, 95% confidence interval [CI] 1.29‐3.75), first office diastolic blood pressure >100 mm Hg (OR = 5.71, 95% CI 1.53‐21.40), and current smoking (OR = 5.91, 95% CI 2.11‐16.56) were independent predictors of NH. Obesity was associated with a reduced risk of NH (OR = 0.43, 95% CI 0.25‐0.75). No association was found between deprivation status or sociodemographic factors and NH. To conclude, NH was identified in more than three out of four patients with high office blood pressure. Male smokers with high diastolic blood pressure were most affected by NH. ABPM may improve hypertension management in these patients.     

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.     

Blood pressure measurement protocol determines hypertension phenotypes in a Middle Eastern population

Clinic blood pressure (BP) measurement remains a crucial step in managing hypertension. While the number of measures recorded in different settings varies, with typically 1‐3 measures, there has been no prior justification for the actual number of measures required. We investigated the pattern of BP variability over 5 consecutive automated readings (R1‐R5) and the influence of patient characteristics on this pattern to identify the phenotype of hypertension in a Middle Eastern population. There were 1389 outpatients (51% men, 49% women), age range (18‐87 y) who had 5 unattended automated consecutive BP measurements with one‐minute intervals using the validated Datascope Mindray Passport V Monitor with the patient blinded from the results. Mean (±SEM) SBP for R1 (136.0 ± 2 mm Hg) was similar to R2 (136.2 ± 2 mm Hg). Thereafter SBP progressively declined till R5 by total of 5.5 mm Hg. The SBP decline was less (4.2 mm Hg) in older (>50 years) vs younger participants (8.1 mm Hg; P < .001) and was blunted in diabetic and hypertensive participants. Overall, 43% of participants had R2 > R1, and 24% additionally had R5 > R1. Age was a strong independent predictor of having both R2 > R1 and R5 > R1, as well as diabetes. Diastolic blood pressure (DBP) decreased by average 2.8 mm Hg from R1 to R5. Females had a 5‐fold greater total decline in DBP vs males (P < .001). Using the mean of 5 BP measures resulted in fewer participants being classified as hypertensive (36% of the population) compared to using one measurement (46%), or established BP guidelines which use different combinations of R1‐R3 (37%‐42%). Our findings in a Middle Eastern population highlight the importance of the BP measurement protocol in combination with patient characteristics in determining whether a patient is diagnosed with hypertension. Protocols that rely on different combinations of only 3 measures (R1‐3) will classify more participants as hypertensive, compared to using 5 measures or disregarding a high R2.     

Algorithm for diagnosing hypertension using out‐of‐office blood pressure measurements

The authors developed and validated a diagnostic algorithm using the optimal upper and lower cut‐off values of office and home BP at which ambulatory BP measurements need to be applied. Patients presenting with high BP (≥140/90 mm Hg) at the outpatient clinic were referred to measure office, home, and ambulatory BP. Office and home BP were divided into hypertension, intermediate (requiring diagnosis using ambulatory BP), and normotension zones. The upper and lower BP cut‐off levels of intermediate zone were determined corresponding to a level of 95% specificity and 95% sensitivity for detecting daytime ambulatory hypertension by using the receiver operator characteristic curve. A diagnostic algorithm using three methods, OBP‐ABP: office BP measurement and subsequent ambulatory BP measurements if office BP is intermediate zone; OBP‐HBP‐ABP: office BP, subsequent home BP measurement if office BP is within intermediate zone and subsequent ambulatory BP measurement if home BP is within intermediate zone; and HBP‐ABP: home BP measurement and subsequent ambulatory BP measurements if home BP is within intermediate zone, were developed and validated. In the development population (n = 256), the developed algorithm yielded better diagnostic accuracies than 75.8% (95%CI 70.1–80.9) for office BP alone and 76.2% (95%CI 70.5–81.3) for home BP alone as follows: 96.5% (95%CI: 93.4–98.4) for OBP‐ABP, 93.4% (95%CI: 89.6–96.1) for OBP‐HBP‐ABP, and 94.9% (95%CI: 91.5–97.3%) for HBP‐ABP.  In the validation population (n = 399), the developed algorithm showed similarly improved diagnostic accuracy. The developed algorithm applying ambulatory BP measurement to the intermediate zone of office and home BP improves the diagnostic accuracy for hypertension.     

Association of optimal blood pressure with mortality in patients taking antihypertensive medications

We investigated the relationship between blood pressure (BP) and mortality in patients taking antihypertensive medications in the Korean using data from the 2007‐2015 Korean National Health and Nutrition Examination Surveys. A total of 6601 patients aged 30‐74 years were included. Systolic BP (SBP) and diastolic BP (DBP) were both divided into four groups as follows: SBP < 120, 120 ≤ SBP ≤ 129 130 ≤ SBP ≤ 139, and SBP ≥ 140; DBP < 70, 70 ≤ DBP ≤ 79, 80 ≤ DBP ≤ 89, and DBP ≥ 90. The survival rates and hazard ratios were evaluated using Kaplan‐Meier curves and multivariable Cox regression analyses. To evaluate the predictability of all‐cause mortality according to SBP and/or DBP, we calculated Harrell''s concordance‐index. The lowest DBP group had a high risk of mortality regardless of the SBP status. The group with DBP < 70 mm Hg and SBP ≥ 140 mm Hg showed the highest mortality. The discriminatory ability calculated using Harrell''s C‐indexes was greater for the combination of SBP and DBP compared to DBP or SBP alone. These results suggest that it is more effective to simultaneously evaluate the effect of SBP and DBP to predict mortality; clinicians should manage DBP < 70 mm Hg when treating hypertensive patients.     

Peak blood pressure‐guided monitoring may serve as an effective approach for blood pressure control in the out‐of‐office setting

We aimed to explore whether diurnal blood pressure (BP) peak characteristics have a significant influence on the association between left ventricular damage with the two BP components (morning BP vs. afternoon peak BP) in untreated hypertensives. This cross‐sectional study included 1084 hypertensives who underwent echocardiography and 24‐h ambulatory BP monitoring. Participants were stratified according to the relationship between morning systolic BP (MSBP; average SBP within 2 h of waking up) and afternoon peak systolic BP (ASBP; average SBP between 16:00 and 18:00). Afternoon and morning hypertension was defined as ≥ 135/85 mm Hg. The morning and afternoon peak BPs occurred at around 7:00 and 17:00, respectively. In general hypertensives, morning BP and afternoon peak BP are significantly different in absolute values (for binary SBP, McNemar''s χ² = 6.42; p = .014). ASBP was more pronounced than MSBP in 602 patients (55.5%), in whom 24‐h SBP showed higher consistency with ASBP than with MSBP (Kappa value: 0.767 vs 0.646, both p < .01). In subjects with ASBP ≥ MSBP, ASBP was associated with left ventricular hypertrophy independent of MSBP (logistic regression analysis odds ratio: 1.046, p < .01), and left ventricular mass index was more strongly correlated with ASBP than with MSBP (multiple regression coefficient β: 0.453, p < .01), in which the relationships held true independently of 24‐h SBP. The opposite results were obtained in subjects with MSBP > ASBP. Peak BP‐guided monitoring may serve as an effective approach to out‐of‐office hypertension monitoring and control, providing the best consistency with 24‐h average SBP and highest discrimination performance for target organ damage, independently of 24‐h SBP.