Monitoring home BP readings just got easier. This novel method of identifying patients with uncontrolled hypertension correlates well with ambulatory BP monitoring. Practice changer: Use this easy "3 out of 10 rule" to quickly sift through home blood pressure readings and identify patients with uncontrolled hypertension who require pharmacologic management. Stength of recommendation: B: Based on a single, good quality, multicenter trial. Sharman JE, Blizzard L, Kosmala W, et al. Pragmatic method using blood pressure diaries to assess blood pressure control. Ann Fam Med. 2016;14:63-69

Hogan, Linda

Jarrett, Jennie B

Lyon, Corey

University of Missouri: MOspace

719JFPONLINE.COM VOL 65, NO 10  |  OCTOBER 2016  |  THE JOURNAL OF FAMILY PRACTICEPriority Updates from the Research Literature from the Family Physicians Inquiries Network PURLs®Jennie B. Jarrett, PharmD, BCPS, MMedEd; Linda Hogan, PhD; Corey Lyon, DO; Kate Rowland, MD, MSUniversity of Pittsburgh Medical Center, St. Margaret Family Medicine Residency Program, Pa (Drs. Jarrett and Hogan); University of Colorado Family Medicine Residency, Denver (Dr. Lyon); Rush Copley Family Medicine Residency, Aurora, Ill (Dr. Rowland)D E P U T Y  E D I T O RAnne Mounsey, MDDepartment of Family Medicine, University of North Carolina, Chapel HillMonitoring home BP   readings just got easierThis novel method of identifying patients with uncontrolled hypertension correlates well with ambulatory BP monitoring.PRACTICE CHANGER Use this easy “3 out of 10 rule” to quickly sift through home blood pressure read-ings and identify patients with uncontrolled hypertension who require pharmacologic management.1STRENGTH OF RECOMMENDATIONB: Based on a single, good quality, multi-center trial.Sharman JE, Blizzard L, Kosmala W, et al. Pragmatic method using blood pressure diaries to assess blood pressure control. Ann Fam Med. 2016;14:63-69.ILLUSTRATIVE CASEA 64-year-old woman presents to your office for a follow-up visit for her hypertension. She is currently managed on lisinopril 20 mg/d and hydrochlorothiazide 25 mg/d without any problems. The patient’s blood pressure (BP) in the office today is 148/84 mm Hg, but her home blood pressure (HBP) readings are much lower (see TABLE). Should you increase her lisinopril dose today?Hypertension has been diagnosed on the basis of office readings of BP for almost a century, but the readings can be so inaccurate that they are not use-ful.2 The US Preventive Services Task Force recommends the use of ambulatory blood pressure monitoring (ABPM) to accurately diagnose hypertension in all patients, while The Seventh Report of the Joint National Committee on Prevention, Detection, Evalu-ation, and Treatment of High Blood Pressure (JNC 7) recommends ABPM for patients sus-pected of having white-coat hypertension and any patient with resistant hyperten-sion,3,4 but ABPM is not always acceptable to patients.5 HBP readings, on the other hand, corre-late well with ABPM measurements and may be more accurate and more predictive of ad-verse outcomes than office measurements, and the process is often more tolerable to patients than ABPM.6-8 If the average home BP reading is >135/85 mm Hg, there is an 85% probability that ambulatory BP will also be high.8Guidelines recommend HBP monitoring for long-term follow-up of hypertensionThe European Society of Hypertension practice guideline on HBP monitoring sug-gests that HBP values <130/80 mm Hg may be considered normal, while a mean HBP ≥135/85 mm Hg is considered elevated.9 The guideline recommends HBP monitoring for 3 to 7 days prior to a patient’s follow-up appointment with 2 readings taken one to 2 minutes apart in the morning and evening.9 In a busy clinic, averaging all of these home values can be time-consuming. So how can primary care physicians accurately and efficiently streamline the process? This study sought to answer that question.CONTINUED720 THE JOURNAL OF FAMILY PRACTICE  |   OCTOBER 2016  |   VOL 65, NO 10PURLs®STUDY SUMMARYWhen 3 of 10 readings are elevated, it’s predictiveThis multicenter trial compared HBP moni-toring to 24-hour ABPM in 286 patients with uncomplicated essential hypertension to determine the optimal percentage of HBP readings needed to diagnose uncontrolled BP (HBP ≥135/85 mm Hg). Patients were included if they were diagnosed with uncomplicated hypertension, not pregnant, ≥18 years of age, and taking ≤3 antihyperten-sive medications. Medication compliance was verified by a study nurse at a clinic visit. Patients were excluded if they had a signifi-cant abnormal left ventricular mass index (women >59 g/m2; men >64 g/m2), coronary artery or renal disease, secondary hyperten-sion, serum creatinine exceeding 1.6 mg/dL, aortic valve stenosis, upper limb obstructive atheroscle-rosis, or BP >180/100 mm Hg.Approximately half of the participants were women (53%), average body mass index was 29.4 kg/m2, and the average number of hyper-tension medications being taken was 2.4. The patients were instructed to take 2 BP readings (one minute apart) at home 3 times daily, in the morning (between 6 am and 10 am), at noon, and in the evening (between 6 pm and 10 pm), and to record only the second reading for 7 days. Only the morning and evening readings were used for analysis in the study. The 24-hour ABP was measured every 30 minutes during the daytime hours and every 60 minutes over- night. The primary outcome was to determine the optimal number of systolic HBP read-ings above goal (135 mm Hg), from the last 10 record-ings, that would best predict elevated 24-hour ABP. Sec-ondary outcomes were various cardiovascular markers of target end-organ damage. ❚ The researchers found that if at least 3 of the last 10 HBP readings were ele- vated (≥135 mm Hg systolic), the patient was likely to have hypertension on 24-hour ABPM (≥130 mm Hg). When patients had <3 HBP elevations out of 10 readings, their mean (±standard deviation [SD]) 24-hour ambulatory daytime systolic BP was 132.7 (±11.1) mm Hg and their mean systolic HBP value was 120.4 (±9.8) mm Hg. When patients had ≥3 HBP elevations, their mean 24-hour ambulatory daytime systolic BP was 143.4 (±11.2) mm Hg and their mean systolic HBP value was 147.4 (±10.5) mm Hg. The positive and negative predictive values of ≥3 HBP elevations were 0.85 (95% confidence interval [CI], 0.78-0.91) and The researchers found that if  at least 3 of the last 10 home BP readings were elevated, the  patient was likely to have hypertension  on 24-hour ambulatory monitoring.TABLE Should you change this patient’s  lisinopril dose?A 64-year-old woman is currently managed on lisinopril 20 mg/d and hydrochlorothiazide 25 mg/d. Her blood pressure (BP) in the office today is 148/84 mm Hg, but her home blood pressure (HBP) readings, as shown below, are much lower. However, the patient’s HBP log notes 3 systolic readings ≥135 mm Hg, indicating uncon-trolled hypertension. In light of Sharman, et al’s1 findings, the dose of lisinopril should be increased to further control this patient’s BP.Date Time 2nd BP reading (mm Hg)9/1/16 7:30 am 124/867:35 pm 135/889/2/16 6:30 am 145/966:35 pm 122/829/3/16 7:45 am 128/787:50 pm 116/749/4/16 6:15 am 130/786:30 pm 126/789/5/16 7:15 am 140/887:00 pm 120/849/6/16 6:45 am 133/866:30 pm 125/859/7/16 7:40 am 123/837:00 pm 124/82BP, blood pressure.721JFPONLINE.COM VOL 65, NO 10  |  OCTOBER 2016  |  THE JOURNAL OF FAMILY PRACTICECONTINUEDPatients using home blood  pressure  monitors should be counseled on how to determine the appropriate cuff size so that measurements are accurate. 0.56 (95% CI, 0.48-0.64), respectively, for a 24-hour systolic ABP of ≥130 mm Hg. Three elevations or more in HBP, out of the last 10 readings, was also an indicator for tar-get organ disease assessed by aortic stiff-ness and increased left ventricular mass and decreased function. The sensitivity and specificity of ≥3 eleva-tions for mean 24-hour ABP systolic readings ≥130 mm Hg were 62% and 80%, respec-tively, and for 24-hour ABP daytime systolic readings ≥135 mm Hg were 65% and 77%, respectively. WHAT’S NEWMonitoring home BP  can be simplifiedThe researchers found that HBP monitor-ing correlates well with ABPM and that their method provides clinicians with a simple way (3 of the past 10 measurements ≥135 mm Hg systolic) to use HBP readings to make clinical decisions regarding  BP management.CAVEATSIdeal BP goals are hazy, and a lot  of patient education is requiredConflicting information and opinions remain regarding the ideal intensive and standard BP goals in different populations.10,11 Systolic BP goals in this study (≥130 mm Hg for overall 24-hour ABP and ≥135 mm Hg for 24-hour ABP daytime readings) are recommended by some experts, but are not commonly recog-nized goals in the United States. This study found good correlation between HBP and ABPM at these goals, and it seems likely that this correlation could be extrapolated for similar BP goals. Other limitations are that: 1) The study focused only on systolic BP goals; 2) Patients in the study adhered to precise instructions on BP monitoring. HBP monitoring requires significant patient education on the proper use of the equipment and the monitoring schedule; and 3) While end-organ complica-tion outcomes showed numerical decreases in function, the clinical significance of these reductions for patients is unclear. CHALLENGES TO IMPLEMENTATIONCost of device and  improper cuff sizes could be barriersThe cost of HBP monitors ($40-$60) has decreased significantly over time, but the devices are not always covered by insur-ance and may be unobtainable for some people. Additionally, patients should be counseled on how to determine the appro-priate cuff size to ensure the accuracy of the measurements. The British Hypertensive Society main-tains a list of validated BP devices on their Web site: http://bhsoc.org/bp-monitors/ bp-monitors.12                         JFPACKNOWLEDGEMENTThe PURLs Surveillance System was supported in part by Grant Number UL1RR024999 from the National Center For Research Resources, a Clinical Translational Science Award to the University of Chicago. The content is solely the responsi-bility of the authors and does not necessarily represent the official views of the National Center For Research Resources or the National Institutes of Health.Copyright © 2016. The Family Physicians Inquiries Network. All rights reserved. References 1.   Sharman JE, Blizzard L, Kosmala W, et al. Pragmatic method us-ing blood pressure diaries to assess blood pressure control. Ann Fam Med. 2016;14:63-69. 2.   Sebo P, Pechère-Bertschi A, Herrmann FR, et al. Blood pressure measurements are unreliable to diagnose hypertension in pri-mary care. J Hypertens. 2014;32:509-517. 3.   Siu AL; U.S. Preventive Services Task Force. Screening for high blood pressure in adults: US Preventive Services Task Force Rec-ommendation Statement. Ann Int Med. 2015;163:778-786. Avail-able at: http://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/high-blood-pres-sure-in-adults-screening. Accessed June 16, 2016. 4.   Chobanian AV, Bakris GL, Black HR, et al. The Seventh Re-port of the Joint National Committee on Prevention, Detec-tion, Evaluation, and Treatment of High Blood Pressure. JAMA. 2003;289:2560-2572.  5.   Mallion JM, de Gaudemaris R, Baguet JP, et al. Acceptability and tolerance of ambulatory blood pressure measurement in the hy-pertensive patient. Blood Press Monit. 1996;1:197-203. 6.   Gaborieau V, Delarche N, Gosse P. Ambulatory blood pressure monitoring versus self-measurement of blood pressure at home: correlation with target organ damage. J Hypertens. 2008;26: 1919-1927. 7.   Ward AM, Takahashi O, Stevens R, et al. Home measurement of blood pressure and cardiovascular disease: systematic review and meta-analysis of prospective studies. J Hypertens. 2012;30: 449-456. 8.   Pickering TG, Miller NH, Ogedegbe G, et al. Call to action on use and reimbursement for home blood pressure monitoring: executive summary. A joint scientific statement from the Ameri-can Heart Association, American Society of Hypertension, and Preventive Cardiovascular Nurses Association. Hypertension. 722 THE JOURNAL OF FAMILY PRACTICE  |   OCTOBER 2016  |   VOL 65, NO 10PURLs®2008;52:1-9. 9.   Parati G, Stergiou GS, Asmar R, et al; ESH Working Group on Blood Pressure Monitoring. European Society of Hypertension practice guidelines for home blood pressure monitoring. J Hum Hypertens. 2010;24:779-785. 10.   The SPRINT Research Group. A randomized trial of inten-sive versus standard blood-pressure control. N Engl J Med. 2015;373:2103-2116. 11.   Brunström M, Carlberg B. Effect of antihypertensive treatment at different blood pressure levels in patients with diabetes mellitus: systematic review and meta-analyses. BMJ. 2016;352:i717. 12.   British Hypertensive Society. BP Monitors. Available at: http://bhsoc.org/bp-monitors/bp-monitors. Accessed June 27, 2016.This supplement is sponsored by Primary Care Education Consortium and Primary Care Metabolic Group and is supported by funding from Novo Nordisk Inc. A SUPPLEMENT TO THE JOURNAL OF FAMILY PRACTICE An Evolutionary Perspective on Basal Insulin in Diabetes TreatmentNOW IN PRINT AND ONLINEDiscussion of primary care topics in basal insulin includes:•   Role of Insulin Therapy in Diabetes•  Basal Insulin in Primary Care•   Innovations in Insulin: Insulin Degludec U-100 and U-200•   Innovations in Insulin: Insulin Glargine U-300AVAILABLE ONLINE AT JFPONLINE.COMPCEC_Insulin1016.indd   1 9/21/16   2:16 PM

Monitoring home BP readings just got easier

Abstract

Similar works

Full text

Available Versions

University of Missouri: MOspace