In a Perspective, Mark Caulfield discusses potential implications of using home blood pressure monitoring for diagnosis and treatment of hypertension. Please see later in the article for the Editors' Summar

K Asayama

K Lovibond

Mark Caulfield

S Lewington

SS Lim

T Krause

PLoS Medicine

PubMed

Caulfield, M

Queen Mary Research Online

Home blood pressure monitoring: new evidence for an expanded role.Caulfield, M     (c) 2014 Mark Caulfield.This is an open-access article distributed under the terms of the Creative CommonsAttribution License, which permits unrestricted use, distribution, and reproduction in anymedium, provided the original author and source are credited  For additional information about this publication click this link.http://qmro.qmul.ac.uk/xmlui/handle/123456789/19178   Information about this research object was correct at the time of download; we occasionallymake corrections to records, please therefore check the published record when citing. Formore information contact scholarlycommunications@qmul.ac.ukPerspectiveHome Blood Pressure Monitoring: New Evidence for anExpanded RoleMark Caulfield*Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United KingdomCardiovascular disease is now the lead-ing cause of death and disability worldwide[1]. The application of electronic bloodpressure measurement (home or ambulato-ry monitoring) has been shown to improvethe precision of diagnosis of hypertensionand is superior to conventional, or clinic,blood pressure monitoring at predictingprognosis in those with high blood pressure.The global burden of hypertension nowaffects over 1 billion people and contributesto 80% of cardiovascular disease outcomesin emergent economies [1]. From observa-tional studies of blood pressure (mostlyclinic blood pressure) in 1 million people,for every 20-mm Hg increment in systolicblood pressure greater than 115 mm Hg,there is an effective doubling of cardiovas-cular mortality [2].The Prognostic Role ofElectronic Blood PressureThere are limited data on the use ofhome blood pressure monitoring (HBPM)to assess the cardiovascular risk of patients.An analysis as part of the 2011 UKNational Institute for Health and CareExcellence guideline for hypertension sug-gested that ambulatory blood pressuremonitoring (ABPM) was superior toHBPM and that both were superior toclinic blood pressure monitoring (CBPM)as a guide to adverse outcomes [3,4]. Thisanalysis led to the recommendation thatABPM be used to confirm a diagnosiswhen hypertension is suspected, but thepanel (in which I was a participant)acknowledged that the relative lack ofdata on HBPM might have affectedprognostic accuracy [3,4].As published in this week’s PLOSMedicine, Jan Staessen and colleaguesundertook an individual-patient meta-analysis based on data from the Interna-tional Database of Home Blood Pressurein Relation to Cardiovascular Outcome.The meta-analysis included 5,008 peoplewho had home and conventional bloodpressure measurements and were not beingtreated with antihypertensive medicationsthat would have influenced prognosticoutcomes [5]. These measurements wereused to stratify participants into fivecategories of blood pressure: optimal,,120/,80 mm Hg; normal, 120–129/80–84 mm Hg; high-normal, 130–139/85–89 mm Hg; mild hypertension, 140–159/90–99 mm Hg; and severe hyperten-sion, $160/$100 mm Hg.Home Blood PressureMonitoring Improves RiskStratificationIn keeping with a previous analysis,the meta-analysis found no significantimprovement in risk stratification in thosedefined as severely hypertensive ($160/$100 mm Hg); at these levels HBPM andCBPM are both strong predictors ofoutcomes. This is not unexpected; severehypertension does not lack precision in riskstratification and is not difficult to decideto treat. On the other hand, at every levelof blood pressure below severe hyperten-sion, the additional measurements ob-tained from HBPM improved risk stratifi-cation, providing new evidence supportingthe use of HBPM in routine assessment ofrisk. This result is important because itcould refine risk stratification in peoplewith optimal, normal, or high-normalblood pressure based on CBPM, who arenot conventionally treated. In addition,HBPM showed improved stratification ofrisk in those with masked hypertension,that is, those who have normal clinic bloodpressure but on HBPM or ABPM haveperiods of elevated blood pressure andmay benefit from treatment [5].These findings add depth to the evi-dence base in favour of electronic bloodpressure monitoring in the form of HBPM.However, the authors do not have data toprovide a head-to-head comparison ofHBPM and ABPM, which would bevaluable in assessing whether HBPMcould be of sufficient diagnostic andLinked Research ArticleThis Perspective discusses thefollowing new study published inPLOS Medicine:Asayama K, Thijs L, Brguljan-Hitij J,Niiranen TJ, Hozawa A, et al. (2014)Risk Stratification by Self-MeasuredHome Blood Pressure across Catego-ries of Conventional Blood Pressure:A Participant-Level Meta-AnalysisPLoS Med 11(1): e1001591. doi:10.1371/journal.pmed.1001591Jan Staessen and colleagues com-pare the risk of cardiovascular,cardiac, or cerebrovascular eventsin patients with normal office bloodpressure but elevated home bloodpressure.Citation: Caulfield M (2014) Home Blood Pressure Monitoring: New Evidence for an Expanded Role. PLoSMed 11(1): e1001592. doi:10.1371/journal.pmed.1001592Published January 21, 2014Copyright:  2014 Mark Caulfield. This is an open-access article distributed under the terms of the CreativeCommons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium,provided the original author and source are credited.Funding: No specific funding was received for writing this article.Competing Interests: The author has declared that no competing interests exist.Abbreviations: ABPM, ambulatory blood pressure monitoring; CBPM, clinic blood pressure monitoring;HBPM, home blood pressure monitoring.* E-mail: m.j.caulfield@qmul.ac.ukProvenance: Commissioned; not externally peer reviewed.Perspectives are commissioned from an expert anddiscuss the clinical practice or public healthimplications of a published study. The originalpublication must be freely available online.PLOS Medicine | www.plosmedicine.org 1 January 2014 | Volume 11 | Issue 1 | e1001592prognostic precision to replace ABPM inthe confirmation of a diagnosis informinga decision to treat. In addition, they werenot able to standardise HBPM approach-es, but that limitation would be more likelyto dilute the observed improved riskstratification by HBPM than create aspurious association. To address this issueand validate these findings, the authorssuggest further comparative, prospectiverandomised controlled trials would bevaluable [5].The Potential Implications ofThese Findings for Patients withHigh Blood PressureAs the authors suggest, the use ofelectronic blood pressure monitoring(HBPM and ABPM) is likely cost-effective,allows more rapid diagnosis and treat-ment, saves consultation time, and may insome people avert treatment at leasttemporarily [6]. In this study by Staessenand colleagues, HBPM appears valuablein assessing those at risk who would notusually be considered as potentially bene-fiting from treatment. With a growingburden of high blood pressure and agrowing availability of affordable devices,HBPM could be used to diagnose highblood pressure and help decide whom totreat. It empowers patients to take on arole in assessment of their blood pressure.Now, with smart phone applications thataccept automated data uploads fromHBPM and display blood pressure trendsover time, HBPM could help avoid traveland may save time for the health careteam as they conduct remote consultationsexploiting electronic tools for communica-tion.AcknowledgmentsM. C. is a National Institute for HealthResearch Senior Investigator and is funded bythe National Institute for Health ResearchCardiovascular Biomedical Research Unit atBarts and The London School of Medicine andDentistry.Author ContributionsWrote the first draft of the manuscript: MC.Contributed to the writing of the manuscript:MC. ICMJE criteria for authorship read andmet: MC. Agree with manuscript results andconclusions: MC.References1. Lim SS, Vos T, Flaxman AD, Danaei G, ShibuyaK, et al. (2012) A comparative risk assessment ofburden of disease and injury attributable to 67risk factors and risk factor clusters in 21 regions,1990–2010: a systematic analysis for the GlobalBurden of Disease Study 2010. Lancet 380:2224–2260. doi:10.1016/S0140-6736(12)61766-82. Lewington S, Clarke R, Qizilbash N, Peto R,Collins R, et al. (2002) Age-specific relevance ofusual blood pressure to vascular mortality: ameta-analysis of individual data for one millionadults in 61 prospective studies. Lancet 360:1903–1913.3. Krause T, Lovibond K, Caulfield M, McCor-mack T, Williams B, et al. (2011) Management ofhypertension: summary of NICE guidance. BMJ343: d4891. doi:10.1136/bmj.d48914. National Clinical Guideline Centre (2011) Hy-pertension: the clinical management of primaryhypertension in adults. Available: http://www.nice.org.uk/nicemedia/live/13561/56007/56007.pdf. Accessed 13 December 2013.5. Asayama K, Thijs L, Brguljan-Hitij J, NiiranenTJ, Hozawa A, et al. (2014) Risk stratification byself-measured home blood pressure across catego-ries of conventional blood pressure: a participant-level meta-analysis. PLoS Med 11: e1001591. doi/10.1371/journal.pmed.10015916. Lovibond K, Jowett S, Barton P, Caulfield M,Heneghan C, et al. (2011) Cost-effectiveness ofoptions for the diagnosis of high blood pressure inprimary care: a modelling study. Lancet 378:1219–1230. doi:10.1016/S0140-6736(11)61184-7PLOS Medicine | www.plosmedicine.org 2 January 2014 | Volume 11 | Issue 1 | e1001592

Home Blood Pressure Monitoring: New Evidence for an Expanded Role

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Caulfield Mark

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Home blood pressure monitoring: new evidence for an expanded role.

A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study

Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies.

Cost-effectiveness of options for the diagnosis of high blood pressure in primary care: a modelling study.

Hypertension: the clinical management of primary hypertension in adults. Available:

Management of hypertension: summary of NICE guidance.

Risk stratification by self-measured home blood pressure across categories of conventional blood pressure: a participantlevel meta-analysis.

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Home Blood Pressure Monitoring: New Evidence for an Expanded Role

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