Is nurse-measured blood pressure a valid substitute for ambulatory blood pressure monitoring?

High blood pressure screening in pharmacies during May Measurement Month campaigns in Switzerland

PURPOSE

May Measurement Month (MMM) is an international screening campaign for arterial hypertension (HT) organised by the International Society of Hypertension and the World Hypertension League. It aims at raising the awareness of elevated blood pressure (BP) in the population. The goal of this analysis was to assess the results obtained in Swiss pharmacies during a 3-year campaign.

MATERIAL AND METHODS

Swiss data from the MMM17 to MMM19 campaigns were extracted from the global MMM database. The analysis was conducted specifically on measures taken in pharmacies. BP and a questionnaire including demographical and clinical information were recorded for each participant. To assess BP control, ESH 2018 thresholds of <140/90 mmHg and ESH 2021 pharmacy-thresholds of <135/85 mmHg were used.

RESULTS

From an initial sample of 3634 Swiss participants included during this 3-year campaign, 2567 participants (73.2%women and 26.8% men, p<.001) had their BP measured in triplicates in pharmacies. The first BP measurement was associated with 2.0 ± 4.9 mmHg effect on systolic blood pressure (SBP) (p<.001) and 0.7 ± 3.7 mmHg on diastolic blood pressure (DBP) (p<.001) compared to the mean of the second and third measurements. Based on the ESH 2018 and the ESH 2021 pharmacy thresholds, prevalence of HT (mean of second and third measurements) increased from 29.5% to 38.3%, respectively. In treated participants, 58.3% (279) had an average BP < 140/90 mmHg and 40.3% (193) had an average BP < 135/85 mmHg.

CONCLUSIONS

HT screening campaigns in pharmacies recruits mainly women. It helps the detection of untreated hypertensive participants and uncontrolled treated participants. Our data suggest that the average BP should be calculated on the second and third measurements due to a significant first measure effect in pharmacies measurement. SummaryHigh blood pressure (BP) is a major global public health issue as the leading risk factor of global death.World-wide initiatives like May Measurement Month (MMM) aim to screen thousands of people each year to raise awareness of hypertension (HT).Switzerland participated in MMM 2017-2019 and screened more than 2500 participants in pharmacies.When adopting the recent proposed thresholds of HT diagnosis in pharmacies (ESH 2021 > 135/85 mmHg), HT prevalence in Switzerland is high (38.3%) with only 2/3 of treated hypertensive achieving the BP goals.Women are more likely to participate in such campaigns taking place in pharmacies.A first measurement effect (FME) was also present in pharmacies, highlighting that taking three BP measurements in pharmacies and discarding the first should be also considered in the pharmacy setting.Involving a routine pharmacy-based health care of patients would help to identify more hypertensive patients and uncontrolled treated patients, who may not have had access to BP measurement.

Screening for Hypertension in Adults: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force

IMPORTANCE

Hypertension is a major risk factor for cardiovascular disease and can be modified through lifestyle and pharmacological interventions to reduce cardiovascular events and mortality.

OBJECTIVE

To systematically review the benefits and harms of screening and confirmatory blood pressure measurements in adults, to inform the US Preventive Services Task Force.

DATA SOURCES

MEDLINE, PubMed, Cochrane Collaboration Central Registry of Controlled Trials, and CINAHL; surveillance through March 26, 2021.

STUDY SELECTION

Randomized clinical trials (RCTs) and nonrandomized controlled intervention studies for effectiveness of screening; accuracy studies for screening and confirmatory measurements (ambulatory blood pressure monitoring as the reference standard); RCTs and nonrandomized controlled intervention studies and observational studies for harms of screening and confirmation.

DATA EXTRACTION AND SYNTHESIS

Independent critical appraisal and data abstraction; meta-analyses and qualitative syntheses.

MAIN OUTCOMES AND MEASURES

Mortality; cardiovascular events; quality of life; sensitivity, specificity, positive and negative predictive values; harms of screening.

RESULTS

A total of 52 studies (N = 215 534) were identified in this systematic review. One cluster RCT (n = 140 642) of a multicomponent intervention including hypertension screening reported fewer annual cardiovascular-related hospital admissions for cardiovascular disease in the intervention group compared with the control group (difference, 3.02 per 1000 people; rate ratio, 0.91 [95% CI, 0.86-0.97]). Meta-analysis of 15 studies (n = 11 309) of initial office-based blood pressure screening showed a pooled sensitivity of 0.54 (95% CI, 0.37-0.70) and specificity of 0.90 (95% CI, 0.84-0.95), with considerable clinical and statistical heterogeneity. Eighteen studies (n = 57 128) of various confirmatory blood pressure measurement modalities were heterogeneous. Meta-analysis of 8 office-based confirmation studies (n = 53 183) showed a pooled sensitivity of 0.80 (95% CI, 0.68-0.88) and specificity of 0.55 (95% CI, 0.42-0.66). Meta-analysis of 4 home-based confirmation studies (n = 1001) showed a pooled sensitivity of 0.84 (95% CI, 0.76-0.90) and a specificity of 0.60 (95% CI, 0.48-0.71). Thirteen studies (n = 5150) suggested that screening was associated with no decrement in quality of life or psychological distress; evidence on absenteeism was mixed. Ambulatory blood pressure measurement was associated with temporary sleep disturbance and bruising.

CONCLUSIONS AND RELEVANCE

Screening using office-based blood pressure measurement had major accuracy limitations, including misdiagnosis; however, direct harms of measurement were minimal. Research is needed to determine optimal screening and confirmatory algorithms for clinical practice.

Screening for high blood pressure in adults: U.S. Preventive Services Task Force recommendation statement

DESCRIPTION

Update of the 2007 U.S. Preventive Services Task Force (USPSTF) reaffirmation recommendation statement on screening for high blood pressure in adults.

METHODS

The USPSTF reviewed the evidence on the diagnostic accuracy of different methods for confirming a diagnosis of hypertension after initial screening and the optimal rescreening interval for diagnosing hypertension.

POPULATION

This recommendation applies to adults aged 18 years or older without known hypertension.

RECOMMENDATION

The USPSTF recommends screening for high blood pressure in adults aged 18 years or older. (A recommendation) The USPSTF recommends obtaining measurements outside of the clinical setting for diagnostic confirmation before starting treatment.

Diagnostic and predictive accuracy of blood pressure screening methods with consideration of rescreening intervals: a systematic review for the U.S. Preventive Services Task Force

BACKGROUND

Elevated blood pressure (BP) is the largest contributing risk factor to all-cause and cardiovascular mortality.

PURPOSE

To update a systematic review on the benefits and harms of screening for high BP in adults and to summarize evidence on rescreening intervals and diagnostic and predictive accuracy of different BP methods for cardiovascular events.

DATA SOURCES

Selected databases searched through 24 February 2014.

STUDY SELECTION

Fair- and good-quality trials and diagnostic accuracy and cohort studies conducted in adults and published in English.

DATA EXTRACTION

One investigator abstracted data, and a second checked for accuracy. Study quality was dual-reviewed.

DATA SYNTHESIS

Ambulatory BP monitoring (ABPM) predicted long-term cardiovascular outcomes independently of office BP (hazard ratio range, 1.28 to 1.40, in 11 studies). Across 27 studies, 35% to 95% of persons with an elevated BP at screening remained hypertensive after nonoffice confirmatory testing. Cardiovascular outcomes in persons who were normotensive after confirmatory testing (isolated clinic hypertension) were similar to outcomes in those who were normotensive at screening. In 40 studies, hypertension incidence after rescreening varied considerably at each yearly interval up to 6 years. Intrastudy comparisons showed at least 2-fold higher incidence in older adults, those with high-normal BP, overweight and obese persons, and African Americans.

LIMITATION

Few diagnostic accuracy studies of office BP methods and protocols in untreated adults.

CONCLUSION

Evidence supports ABPM as the reference standard for confirming elevated office BP screening results to avoid misdiagnosis and overtreatment of persons with isolated clinic hypertension. Persons with BP in the high-normal range, older persons, those with an above-normal body mass index, and African Americans are at higher risk for hypertension on rescreening within 6 years than are persons without these risk factors.

PRIMARY FUNDING SOURCE

Agency for Healthcare Research and Quality.

Does blood pressure change in treated hypertensive patients depending on whether it is measured by a physician or a nurse?

OBJECTIVES

To determine whether there are differences between blood pressure (BP) measured by the nurse (NBP), BP measured by the physician (PBP) and self-measured BP in treated hypertensive patients and, if found, to evaluate their clinical importance.

METHOD

An observational study is carried out with hypertensive patients recruited from two village-based community health centres in Catalonia (Spain) serving an area with a total population of 2800 inhabitants. All patients treated for hypertension visiting the health centre on a specific day of the week and during the same timetable between October 2000 and May 2001 were included.

RESULTS

The difference between physician-systolic BP and nurse-systolic BP was 5.16 mmHg (95% CI 2.62-7.7; p<0.001). The difference between physician-systolic BP and self-measured systolic BP was 4.67 mmHg (95% CI 0.89-8.44; p=0.016). The differences between nurse-systolic BP and self-measured systolic BP were not significant (0.49 mmHg; 95% CI 3.71-2.71; p=0.758). With regards to diastolic BP, no significant differences were found between the different ways of measurement. NBP gave the following values: sensitivity (Sn) of 92% and specificity (Sp) of 60%; positive predictive value (PPV) of 65.7% and negative predictive value (NPV) of 90% with a positive coefficient of probability (CP+) of 2.3 and a negative coefficient of probability (CP-) of 0.133. PBP gave the following results: Sn=72%; Sp=66.7%; PPV=64.3%; NPV=74.1%; CP+=2.16 and CP- = 0.420.

CONCLUSION

Systolic BP measured by the nurse in treated hypertensive patients is significantly lower than the readings obtained by the physician, and are almost identical to ambulatory BP monitoring. Blood pressure determination by the nurse is desirable not only for diagnosis but also to evaluate the level of control of blood pressure during the follow-up of treated hypertensive patients.

Limited (6-h) ambulatory blood pressure monitoring is a valid replacement for the office blood pressure by trained nurse clinician in the diagnosis of hypertension

OBJECTIVE

To assess the ability of limited ambulatory blood pressure monitoring as a valid replacement for office blood pressure measurement done to American Heart Association criteria in diagnosing hypertension.

METHODS

In all, 105 adults, who had been referred for limited ambulatory blood pressure monitoring, participated in the study. Limited ambulatory blood pressure monitoring consisted of 6 h of blood pressure measurement while ambulatory at the Mayo Clinic, using a SpaceLabs 90207 (SpaceLabs Medical, Issaquah, Washington, USA) collecting six readings per hour for the period of observation. The study participants gave consent for three additional consecutive office blood pressure measurements, using a validated aneroid device, done to American Heart Association criteria, by a single hypertension nurse specialist.

RESULTS

Mean systolic blood pressure by limited ambulatory blood pressure monitoring was 137.9+/-14.2 mmHg and for the nurse, 137.9+/-20.1 mmHg. Mean diastolic blood pressure by limited ambulatory blood pressure monitoring was 81.5+/-9.7 mmHg and for the nurse, 74.3+/-11.9 mmHg. The intermethod difference for systolic blood pressure was 0.03+/-12.5 mmHg and diastolic blood pressure, -7.2+/-8.0 mmHg. Using <140/90 as criteria factor, limited ambulatory blood pressure monitoring and the trained nurse agreed 77% of the time on whether the patient was hypertensive. This agreement increased to 81% if the participant's referral blood pressure was >or=140/90.

CONCLUSIONS

Limited ambulatory blood pressure monitoring is an excellent replacement for office blood pressure, done to American Heart Association criteria, in diagnosing hypertension. This avoids issues of variability introduced by the observers, such as digit preference and bias, and increases reproducibility of blood pressure measurements. The appropriate normal value for limited ambulatory blood pressure monitoring is <140/90 mmHg compared with <135/85 mmHg used in 24-h ambulatory blood pressure monitoring.

Comparison of blood pressure measurement consistency using tonometric and automated oscillometric instruments

To effectively evaluate treatments for hypertension, researchers and clinicians must be able to measure blood pressure (BP) in a valid and reliable way. The purpose of this study is to compare measurements made in the clinic using beat-to-beat radial BP tonometry, measurements made during 24 hours using an ambulatory BP monitor, and measurements made in the clinic using an automated oscillometric BP monitor. Fifty-seven adults with primary hypertension participated in this study, which used a repeated measures descriptive design. Clinic and ABPM daytime averages were compatible for both SBP and DBP. In contrast, clinic SBP was 7.56 mmHg higher than the beat-to-beat SBP; clinic DBP was 9.83 mmHg higher than the beat-to-beat DBP. These data suggest that automated clinic measurements may be used in place of daytime ambulatory BP measurements. We also estimate sample sizes for future studies based on characteristics of clinic BP.