Accuracy of telemedical home blood pressure measurement in the diagnosis of hypertension

This study was conducted to compare the accuracy of clinic blood pressure (CBP) and telemedical home blood pressure (HBP) measurement in the diagnosis of hypertension in primary care. The study subjects were 411 patients with average CBP > or =140 mmHg systolic or > or =90 mmHg diastolic, who performed telemedical HBP measurement (5 days, four times daily) and ambulatory blood pressure (ABP) monitoring in random order. Main outcome measure was the agreement of CBP and HBP with daytime ABP. CBP was much higher than daytime ABP and average HBP (P<0.001) with no difference between the latter two. The correlation between CBP and ABP was weak (systolic: r=0.499, diastolic: r=0.543), whereas strong correlations existed between HBP and ABP (systolic: r=0.847, diastolic: r=0.812). A progressive improvement in the strength of the linear regression between average HBP of single days and ABP was obtained from day 1 to day 4, with no further benefit obtained on the fifth day. The HBP readings taken at noon and in the afternoon showed significantly stronger correlations with ABP than the blood pressures measured in the morning and in the evening. In conclusion, the accuracy of telemedical HBP measurement was substantially better than that of CBP in the diagnosis of hypertension in primary care. HBP most accurately reflected ABP on the fourth day of monitoring, and the readings at noon and in the afternoon seemed to be most accurate.     

Cost-effectiveness of the introduction of home blood pressure measurement in patients with office hypertension

OBJECTIVE: Cost-effectiveness of hypertension treatment is an important social and medical issue in Western as well as in Eastern countries, including Japan. Home blood pressure (HBP) measurements have a stronger predictive power for cardiovascular events than casual clinic blood pressure (CBP) measurements. Therefore, the introduction of HBP measurement for the diagnosis and treatment of hypertension should lead to a decrease in medical expenditure. This study presents calculations of the cost savings likely to take place when HBP is implemented for newly detected hypertensive subjects in Japan. DESIGN AND METHODS: We estimate the cost savings from the perspective of a Japanese healthcare system. To estimate the costs associated with changing from CBP to HBP measurement as the diagnostic tool, we constructed a simulation model using data from the Ohasama study. These calculations are based on current estimates for cost of treatment, prevalence of white-coat hypertension at baseline, and varying the incidence of new hypertension after the initial screening. RESULTS: When HBP measurement is not incorporated into the diagnostic process, the medical cost is estimated at US$10.89 million per 1000 subjects per 5 years. When HBP measurement is incorporated, the medical cost is estimated at US$9.33 million per 1000 subjects per 5 years. The reductions in medical costs vary from US$674,000 to US$2.51 million per 1000 subjects per 5 years for treatment of hypertension, when sensitivity analysis is performed. CONCLUSIONS: The introduction of HBP measurement for the treatment of hypertension is very useful for reducing medical costs.     

The unilateral measurement of blood pressure may mask the diagnosis or delay the effective treatment of hypertension

Several studies have indicated the presence of significant interarm blood pressure (BP) differences; this could result in misclassification of BP status. Nevertheless, the findings of these studies were not consistent. This prospective, observational study investigated the presence and magnitude of interarm BP differences and determined the influence of age, gender, arm circumference, smoking, being hypertensive or diabetic, or having a previous history of cardiovascular disease in these differences. The study included 384 subjects, who were patients, ward visitors, and members of the nursing staff of this Department. BP measurements were recorded simultaneously in both arms by using 2 validated, fully automated oscillometric electronic devices. There were significant differences between the right arm and left arm systolic BP (p < 0.0005), between right arm and left arm diastolic BP (p < 0.05), and between right arm and left arm pulse pressure (p = 0.006). The mean interarm differences in systolic and diastolic BP measurements were 1.2 +/-5.0 mm Hg and 0.4 +/-4.2 mm Hg, respectively. There were 13 subjects (3.4%) and 4 subjects (1.04%) with an interarm systolic and diastolic BP difference of > 10 mm Hg, respectively, and a single patient with both interarm systolic and diastolic BP differences of > 10 mm Hg (0.26%). None of the studied demographic or clinical characteristics was a significant predictor of interarm systolic and diastolic BP differences. The authors conclude that significant interarm systolic and diastolic BP differences are frequently present. Therefore, the unilateral measurement of BP may mask the diagnosis or delay the effective treatment of hypertension. It is thus recommended that BP should be simultaneously measured in both arms at the initial consultation and the higher of the 2 readings should be used to guide further management decisions.     

Practical advice for home blood pressure measurement

Early diagnosis of hypertension is one benefit of home blood pressure monitoring. Home measurement may also be used for the detection of masked hypertension. Home blood pressure readings have a strong correlation with risk, and the method has many advantages over office measurement in the management of hypertension, especially in patients with chronic kidney disease or diabetes. The present article provides practical advice on incorporating home blood pressure monitoring into practice. Patient education and training are discussed, as are tips to aid in the selection of devices for blood pressure measurement at home.     

The role of home blood pressure measurement in managing hypertension: an evidence-based review

This article reviews the current literature regarding the role of home measurement of blood pressure (BP) in the management of hypertension. Subjects with hypertension can use simple automated devices to measure their own BP at home. The results can be accurate and reliable, and because multiple readings allow a mean value to be calculated, a better estimate of the underlying BP level is obtained. Home measurement of BP gives results which are equivalent to the accepted 'gold standard' measure of ambulatory BP values, whilst using a simpler and much less expensive technique which is therefore more widely available. Both methods are better than conventional office measurements in identifying the 'true' or underlying mean BP level and identifying falsely raised levels or 'white coat hypertension'. White coat hypertension confounds the treatment of hypertension, but may not be entirely harmless. Ambulatory BP is a better predictor of cardiovascular prognosis than clinic BP. The use of home BP measurement as an equivalent, feasible, and (apparently) more cost-effective technique to measure BP in hypertension, should enable groups of patients with a poorer prognosis to be identified and their treatment adjusted in order to improve their prognosis.     

Blood pressure behavior in the nursing home: implications for diagnosis and treatment of hypertension

OBJECTIVES: To determine patterns of elevated blood pressure (BP) behavior, their clinical correlates, and the relationship to diagnosis and management of hypertension. DESIGN: A cross-sectional, prevalence survey. SETTING: Forty-five nursing homes owned or managed by a large national chain. PARTICIPANTS: A total of 857 older residents (mean age = 84 years). MEASUREMENTS: Supine and standing (1 and 3 minutes) BP and heart rate, taken four times in one day (before and after breakfast, and before and after lunch) by trained nurses using a random zero sphygmomanometer; medication profile; active medical diagnoses; functional status; sociodemographics. RESULTS: The prevalence of a single, elevated, supine systolic pressure (> or = 160 mm Hg) was 14.3%, and of two to four elevated measures was 14.9%. The pre-breakfast reading was consistently the highest, and mean systolic pressures decreased after breakfast. Compared with those not treated, older residents taking antihypertensive medications had higher systolic pressures at all times and showed the same pattern of decline after breakfast. Isolated diastolic hypertension was uncommon (0.9%). Cardiovascular disease, orthostatic hypotension, diabetes, and use of angiotensin converting enzyme inhibitors or calcium channel blockers were more prevalent among older residents who had elevated pressures on multiple occasions (P < .03). Successful antihypertensive treatment was associated with a lower prevalence of orthostatic hypotension. Diuretic use was more likely to be associated with blood pressure control. CONCLUSION: The diagnosis of hypertension in frail older people would benefit from multiple, within-day measures, including postural BP, taken before and after meals. Diuretic use alone, or in conjunction with ACE inhibitors or calcium channel blockers, was more likely to be associated with normalized blood pressures.     

Automated blood pressure measurement for diagnosing hypertension

Guidelines for the management of hypertension have started to include home blood pressure (BP) and 24-h ambulatory BP monitoring as preferred methods for diagnosing hypertension. The next step will be to incorporate automated office BP measurement into the algorithm for diagnosing hypertension. Recent studies support this approach with automated office BP readings being closely correlated with the ambulatory BP.     

Prognostic value of home blood pressure measurement

Although self-monitoring of blood pressure by patients at home is being widely used in clinical practice, the evidence on its prognostic value is still limited. Five long-term studies with nearly 60,000 patients/year have provided prognostic information for home blood pressure measurements. Differences exist among these studies regarding the population characteristics, the sample size and follow-up, the methodology and protocol for office and home blood pressure measurement and the adjustment procedure for other risk factors. All these studies, nevertheless, showed systolic home blood pressure to be a significant predictor of cardiovascular risk, and three of them also showed prognostic value of diastolic home blood pressure. Moreover, the prognostic value of home blood pressure appeared to be consistently superior to that of conventional office measurements. The prognostic significance of the white coat and the masked hypertension phenomena detected by home measurements were investigated in two studies, one in treated hypertensive patients and another in a general population sample. These studies showed that patients with white-coat phenomenon have similar cardiovascular risk as those with low office and home blood pressure, whereas the masked hypertension phenomenon is associated with high risk as in patients with uncontrolled hypertension. In conclusion, the available evidence suggests that home blood pressure has strong prognostic value, which appears to be superior to that of the conventional office measurements. More outcome studies on the prognostic value of home blood pressure, however, are needed.     

What is the value of home blood pressure measurement in patients with mild hypertension?

To investigate the value of home blood pressure (BP) measurements, the BP was recorded daily by the patient at home and compared with recordings in the physician's office and with a 24-hour BP recording taken with a noninvasive ambulatory BP recorder in a group of 93 patients with mild untreated hypertension. Office BPs (mean 148/94 mm Hg) were higher than either home (138/89 mm Hg) or average 24-hour BPs (131/89 mm Hg). For systolic BP, home and office measurements gave similar correlations with 24-hour BP (0.67 and 0.55). For diastolic BP, however, home readings were lower and more accurate (0.76 vs 0.36). Thus, our findings indicate that home readings reflect the overall level of BP more reliably than office readings, and if due consideration is given to the fact that they are usually lower than office readings, they may be used as an alternative and cost-effective means of evaluating patients with mild hypertension.     

Orthostatic hypertension: home blood pressure monitoring for detection and assessment of treatment with doxazosin

To determine the role of home blood pressure (BP) monitoring for a reproducible assessment of orthostatic hypertension (OHT) and the effectiveness of hypertension control by doxazosin. In this study, 605 medicated hypertensive outpatients were enrolled. Home BP in the sitting and standing positions was monitored in all patients in the morning and evening for 6 months. According to an open-label multicenter trial design, the patients were randomly allocated to either an intervention group that took doxazosin (1-4 mg) at bedtime or to a control group that did not receive any add-on medication. The patients were divided into deciles of orthostatic BP change as evaluated by home BP monitoring at baseline. Those in the top decile, in the lowest decile and in deciles two through eight were then assigned to the OHT group, the orthostatic hypotension group and the orthostatic normotension group, respectively.Orthostatic BP in the OHYPO group did not change, whereas that of the OHT group was markedly reduced by doxazosin (P<0.01). In the control group, classification into orthostatic BP categories using home BP monitoring was more reproducible (κ coefficient: 0.42-0.50) than when using clinical BP (κ coefficient: 0.13-0.24). In all groups, a reduction in the urinary albumin/creatinine ratio was significantly associated with a reduction in orthostatic BP doxazosin (P<0.001).The identification of OHT based on home BP monitoring was highly reproducible. The administration of doxazosin might control OHT and consequently prevent target organ damage.     

Patients' experiences and opinions of home blood pressure measurement

Regular measurement of the blood pressure (BP) is necessary to monitor the treatment of hypertension, and self-measurement is one technique of obtaining such measurements. The aim of this study was to investigate the experiences of individuals who have carried out home BP measurement. A qualitative method using semistructured interviews was used with 13 subjects. These were adults with hypertension who had previous experience of measuring their own BP, and were recruited to the study from one UK general medical practice. Interviews were recorded and transcribed, and data from the interviews have been analysed using phenomenological principles and identifying 'meaning units.' The findings suggest that participants were willing to carry out home measurements and several were pleased to have been asked to be more involved in their own management. All found the technique straightforward. Most noted marked variability in the day-to-day BP measurements. Several exhibited the 'white coat' phenomenon (spuriously raised BP in certain settings only). Some participants showed considerable know-ledge of hypertension and its consequences. They reported being aware of their own BP level and whether this was within acceptable limits. They also reported being willing to take further measurements, and to consider adjusting their treatment in the light of these measurements. Other participants showed less knowledge and enthusiasm, and considered the management of hypertension to be the doctor's job. The findings suggest that for some individuals home BP measurement is acceptable. They also help to explain why, for some individuals, it is not. Using the findings, a number of changes to current practice could be made, which might make home measurements more acceptable and easier to perform. As a result, a new proforma for use in everyday practice has been designed. The study shows that there is considerable scope for sharing BP measurement and management decisions in hypertension with patients themselves.     

清晨血压在高血压诊治中的价值

目的分析清晨血压监测在高血压诊治中的临床价值。方法选取2014年9月~2014年10月我院接收的高血压患者308例,通过动态血压监测,选取全天收缩压、舒张压均增高的高血压患者100例,将清晨血压、下午血压与全天血压进行比较。结果清晨收缩压、舒张压与全天收缩压、舒张压无统计学差异。下午收缩压、舒张压与全天收缩压、舒张压有统计学差异。进一步行相关性分析,得出清晨血压与全天血压存在较好的相关性,其中清晨收缩压与全天收缩压相关性最高,(R=0.6339,p0.001)。结论清晨血压可真实地反映全天血压,有利于高血压的筛查及临床诊治效果的评估。     

动态血压监测在高血压诊治中的价值

目的分析动态血压监测应用于高血压诊治中的临床价值。方法选取2011年9月-2013年9月接收的高血压患者(研究组)以及血压正常的体检者(对照组)各70例,均分别进行动态血压和常规方式血压监测,对两组采用不同监测方式的24h血压和脉压监测值,以及白天和夜间的血压和脉压监测值分别比较分析。结果研究组在不同监测方式下,24h血压监测值以及白天和夜间血压平均监测值均存在明显性差别(P0.05),对照组则均无明显性的差别(P0.05)。结论动态血压监测应用于高血压诊治中,可对血压进行更准确的监测,利于临床诊治效果的改善和心脑血管疾病等发生率的降低,有重要的应用价值。     

Effect of ambulatory blood pressure monitoring on the diagnosis and cost of treatment for mild hypertension

Detection of mild hypertension by a small number of casual blood pressures may be inaccurate for the determination of average blood pressure. Nonetheless, casual pressures remain the basis for the diagnosis and treatment of hypertensive patients. We compared casual and noninvasive ambulatory blood pressure monitoring in a consecutive series of 60 subjects evaluated for possible mild hypertension on the basis of casual pressures. Ambulatory blood pressure monitoring was performed on days of usual activity. Correlations between casual systolic and average ambulatory systolic pressures or casual diastolic and average ambulatory diastolic pressures were not significant. Nearly half of the subjects had average ambulatory systolic pressures less than 130 mm Hg. Sixty percent had average ambulatory diastolic pressures less than 85 mm Hg. Nearly 40% had both systolic and diastolic pressures less than those limits. A preliminary analysis of the effects of these results on the short-term cost of antihypertensive treatment was made, assuming that treatment could be withheld from those with average ambulatory pressures less than 130/85 mm Hg. This approach suggests that ambulatory blood pressure monitoring need not increase overall cost, if the results of this evaluation are used in the decision to treat.     

Inaccuracy of seven popular sphygmomanometers for home measurement of blood pressure

Seven models, available commercially for the self-measurement of blood pressure, were subjected to a validation procedure in which three devices of each model were tested by observers who were trained to a high standard of accuracy. The models were the Omron HEM-400C, the Philips HP5308, the Healthcheck 'Cuffless' CX-5 060020, the Nissei Analogue Monitor, the Philips HP5306/B, the Systema Dr MI-150 and the Fortec Dr MI-100. The validation programme had a number of unique features which included assessment of interdevice variability before and after 1 month of home use, and a new form of analysis, which we term 'clinical', based on the likely influence of three grades of device inaccuracy on patient management. In the main validation phase, one device of each model was compared with simultaneous measurements made by two 'blinded' observers using a standard mercury sphygmomanometer (PyMaH Corporation, New Jersey, USA) in the same arm in 85 subjects with a wide range of blood pressures. Three models (the Healthcheck 'Cuffless' CX-5 060020, the Systema Dr MI-150 and the Fortec Dr MI-100) failed the interdevice variability tests and did not reach the main validation test. Two models (the Omron HEM-400C and the Philips HP5306/B) failed on the criteria set down by the American National Standard for Electronic or Automated Sphygmomanometers, as well as the 'clinical' criteria. The remaining two models (the Nissei Analogue Monitor and the Philips HP5308) were acceptable for the measurement of systolic blood pressure by both methods of analysis but failed in the 'clinical' analysis for diastolic blood pressure. The mercury sphygmomanometer was comfortably within the criteria for both methods of analysis.