Changes in Home Versus Clinic Blood Pressure With Antihypertensive Treatments: A Meta-Analysis

Home blood pressure (HBP) monitoring is recommended for assessing the effects of antihypertensive treatment, but it is not clear how the treatment-induced changes in HBP compare with the changes in clinic blood pressure (CBP). We searched PubMed using the terms “home or self-measured blood pressure,” and selected articles in which the changes in CBP and HBP (using the upper arm oscillometric method) induced by antihypertensive drugs were presented. We performed a systematic review of 30 articles published before March 2008 that included a total of 6794 subjects. As there was significant heterogeneity in most of the outcomes, a random effects model was used for the meta-analyses. The mean changes (±SE) in CBP and HBP (systolic/diastolic) were −15.2±0.03/−10.3±0.03 mm Hg and −12.2±0.04/−8.0±0.04 mm Hg respectively, although there were wide varieties of differences in the reduction between HBP and CBP. The reductions in CBP were correlated with those of HBP (systolic BP; r=0.66, B=0.48, diastolic BP; r=0.71, B=0.52, P<0.001). In 7 studies that also included 24-hour BP monitoring, the reduction of HBP was greater than that of 24-hour BP in systolic (HBP; −12.6±0.06 mm Hg, 24-hour BP; −11.9±0.04 mm Hg, P<0.001). In 5 studies that included daytime and nighttime systolic BP separately, HBP decreased 15% more than daytime ambulatory BP and 30% more than nighttime ambulatory BP. In conclusion, HBP falls ≈20% less than CBP with antihypertensive treatments. Daytime systolic BP falls 15% less and nighttime systolic BP falls 30% less than home systolic BP

Race differences in the physical and psychological impact of hypertension labeling

Background - Blood pressure screening is an important component of cardiovascular disease prevention, but a hypertension diagnosis (i.e., label) can have unintended negative effects on patients' well-being. Despite persistent disparities in hypertension prevalence and outcomes, whether the impact of labeling differs by race is unknown. The purpose of this study was to evaluate possible race differences in the relationship between hypertension labeling and health-related quality of life and depression. Methods - The sample included 308 normotensive and unmedicated hypertensive subjects from the Neighborhood Study of Blood Pressure and Sleep, a cross-sectional study conducted between 1999 and 2003. Labeled hypertension was defined (by self-report) as having been diagnosed with high blood pressure or prescribed antihypertensive medications. Effects of labeling and race on self-reported physical and mental health and depressive symptoms were tested using multivariate analysis of covariance, controlling for age, sex, body mass index (BMI), previous medication use, and “true” hypertension status, defined by average daytime ambulatory blood pressure (ABP). Results - Both black and white subjects who had been labeled as hypertensive reported similarly poorer physical health than unlabeled subjects (P = 0.001). However, labeling was associated with poorer mental health and greater depressive symptoms only among blacks (Ps < 0.05 for the interactions). These findings were not explained by differences in socioeconomic status. Conclusions - These results are consistent with previous studies showing negative effects of hypertension labeling, and demonstrate important race differences in these effects. Clinical approaches to communicating diagnostic information that avoid negative effects on well-being are needed, and may require tailoring to patient characteristics such as race

Preventing misdiagnosis of ambulatory hypertension: algorithm using office and home blood pressures

Objectives—An algorithm for making a differential diagnosis between sustained and white coat hypertension (SH and WCH) has been proposed–patients with office hypertension undergo home blood pressure monitoring (HBPM) and those with normal HBP levels undergo ambulatory blood pressure monitoring (ABPM). We tested whether incorporating an upper office blood pressure (OBP) cutoff in the algorithm, higher than the traditional 140/90 mmHg, reduces the need for HBPM and ABPM. Methods—229 normotensive and untreated mildly hypertensive participants (mean age 52.5 ± 14.6, 54% female) underwent OBP measurements, HBPM, and 24-hour ABPM. Using the algorithm, sensitivity (SN), specificity (SP), and positive and negative predictive values (PPV, NPV) for SH and WCH were assessed. We then modified the algorithm utilizing a systolic and diastolic OBP cutoff at a SP of 95% for ambulatory hypertension –those with office hypertension but OBP levels below the upper cutoff undergo HBPM and subsequent ABPM if appropriate. Results—Using the original algorithm, SN and PPV for SH were 100% and 93.8%. Despite a SP of 44.4%, NPV was 100%. These values correspond to SP, NPV, SN, and PPV for WCH respectively. Using the modified algorithm, the diagnostic accuracy for SH and WCH did not change. However, far fewer participants needed HBPM (29 vs. 84) and ABPM (8 vs. 15). Conclusions—In this sample, the original and modified algorithms are excellent at diagnosing SH and WCH. However, the latter requires far fewer subjects to undergo HBPM and ABPM. These findings have important implications for the cost-effective diagnosis of SH and WCH

Franz Volhard lecture: should doctors still measure blood pressure? The missing patients with masked hypertension

The traditional reliance on blood pressure (BP) measurement in the medical setting misses a significant number of individuals with masked hypertension, who have normal clinic BP but persistently high daytime BP when measured out of the office. We suggest that masked hypertension may be a precursor of clinically recognized sustained hypertension and is associated with increased cardiovascular risk compared with consistent normotension. We discuss factors that may contribute to clinic–daytime BP differences as well as the changing relationship between these two measures over time. Anxiety at the time of BP measurement and having been diagnosed as hypertensive appear to be two possible mechanisms. The identification of individuals with masked hypertension is of great clinical importance and requires out-of-office BP screening. Ambulatory BP monitoring is the best established technique for doing this, but home monitoring may be applicable in the future

What is the optimal interval between successive home blood pressure readings using an automated oscillometric device?

Objectives: To clarify whether a shorter interval between three successive home blood pressure (HBP) readings (10 s vs. 1 min) taken twice a day gives a better prediction of the average 24-h BP and better patient compliance. Design: We enrolled 56 patients from a hypertension clinic (mean age: 60 ± 14 years; 54% female patients). The study consisted of three clinic visits, with two 4-week periods of self-monitoring of HBP between them, and a 24-h ambulatory BP monitoring at the second visit. Using a crossover design, with order randomized, the oscillometric HBP device (HEM-5001) could be programmed to take three consecutive readings at either 10-s or 1-min intervals, each of which was done for 4 weeks. Patients were asked to measure three HBP readings in the morning and evening. All the readings were stored in the memory of the monitors. Results: The analyses were performed using the second–third HBP readings. The average systolic BP/diastolic BP for the 10-s and 1-min intervals at home were 136.1 ± 15.8/77.5 ± 9.5 and 133.2 ± 15.5/76.9 ± 9.3 mmHg (P = 0.001/0.19 for the differences in systolic BP and diastolic BP), respectively. The 1-min BP readings were significantly closer to the average of awake ambulatory BP (131 ± 14/79 ± 10 mmHg) than the 10-s interval readings. There was no significant difference in patients' compliance in taking adequate numbers of readings at the different time intervals. Conclusion: The 1-min interval between HBP readings gave a closer agreement with the daytime average BP than the 10-s interval

Nocturnal nondipping of heart rate predicts cardiovascular events in hypertensive patients

Objective: It has not been established whether nocturnal nondipping of heart rate (HR) predicts future cardiovascular disease (CVD). We performed this study to test the hypothesis that nocturnal nondipping of HR predicts the risk of incident CVD independent of nocturnal blood pressure dipping pattern. Methods: Ambulatory blood pressure monitoring was performed in 457 uncomplicated patients, who were being treated or evaluated for hypertension. They were followed for an average of 72 ± 26 months. Nondipping HR was defined as a night/day HR ratio greater than 0.90. We chose two outcomes for this analysis: CVD events (defined as stroke, myocardial infarction, or sudden cardiac death) and all-cause mortality. Cox regression analyses (stepwise method) were used to estimate hazard ratios and their 95% confidence interval after adjusting for covariates. Results: In univariate analysis, increased sleep HR and nondipping of HR were associated with increased risk of CVD and all-cause mortality, but awake HR was not. In multivariable analyses, HR nondipping status significantly predicted an increased risk of CVD events (hazard ratio, 2.37; 95% confidence interval, 1.22–4.62; P = 0.01), but not for all-cause mortality. Increased 24-h HR was significantly associated with increased risk of all-cause mortality (hazard ratio, 1.67; 95% confidence interval, 1.11–2.51; P = 0.01). Conclusion: The risk of future CVD was shown to be 2.4 times higher in those whose HR does not exhibit the typical nocturnal decline. The relationship was independent of nondipping of SBP and was not dependent on diabetes status or blood pressure level

Night Time Blood Pressure Variability Is a Strong Predictor for Cardiovascular Events in Patients With Type 2 Diabetes

Background: We aimed this study to test the hypothesis that short-term blood pressure (BP) variability and abnormal patterns of diurnal BP variation, evaluated by ambulatory BP (ABP), predicts risk of incident cardiovascular disease (CVD) in patients with type 2 diabetes (T2DM). Methods: ABP monitoring (ABPM) was performed in 300 patients with uncomplicated T2DM without known CVD and without BP medications, who were followed for 54 ± 20 months. The relationships of different measures of BP variability, the presence of abnormal patterns of diurnal BP variation (nondipper, riser, or morning BP surge) and the standard deviations of awake and asleep ABP were determined. Cox proportional hazards models were used to estimate hazard ratios (HRs) and their 95% confidence intervals (CIs) before and after controlling for various covariates. Results: The mean age was 67.8 ± 9.6 years, 48% were male, 253 (84%) had a diagnosis of hypertension, and the mean of the standard deviations of awake systolic BP/diastolic BP (SBP/DBP) were 18 ± 6/11 ± 4 mm Hg, and those of sleep SBP/DBP were 13 ± 5/9 ± 3 mm Hg. During follow-up, there were 29 cardiovascular events. In multivariable analyses, the standard deviations of sleep SBP (HR = 1.08; 95% CI, 1.01–1.16, P < 0.05) and sleep DBP (HR = 1.13; 1.04–1.23, P < 0.01) were independently associated with incident CVD. Neither the nondipper and riser patterns nor the morning BP surge were associated with incident CVD events independently of clinic and 24-h BP levels. Conclusions: Abnormal diurnal BP variation was not a predictor of CVD in patients with T2DM. Night time BP variability was an independent predictor of future incidence of CVD, suggesting that this measure could reflect pathophysiology of T2DM