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Bradley CK, Choi E, Abdalla M, Mizuno H, Lam M, Cepeda M, Sangapalaarachchi D, Liu J, Muntner P, Kario K, Viera AJ, Schwartz JE, Shimbo D. Use of Different Blood Pressure Thresholds to Reduce the Number of Home Blood Pressure Monitoring Days Needed for Detecting Hypertension. Hypertension 2023; 80:2169-2177. [PMID: 37577827 PMCID: PMC10530450 DOI: 10.1161/hypertensionaha.123.21118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 07/28/2023] [Indexed: 08/15/2023]
Abstract
BACKGROUND Home blood pressure (BP) monitoring over a 7-day period is recommended to confirm the diagnosis of hypertension. METHODS We determined upper and lower home BP thresholds with >90% positive predictive value and >90% negative predictive value using 1 to 6 days of monitoring to identify high home BP (systolic BP ≥130 mm Hg or diastolic BP ≥80 mm Hg) based on 7 days of home BP monitoring. The sample included 361 adults from the Improving the Detection of Hypertension Study who were not taking antihypertensive medication. We used two 7-day periods, at least 3 days apart, the first being a sampling period and the second a reference period. For each number of days in the sampling period, we determined the percentage of participants who had a high likelihood of having (>90% positive predictive value) or not having (>90% negative predictive value) high BP and would not need to continue home BP monitoring. Only the participants in an uncertain category (ie, positive predictive value ≤90% and negative predictive value ≤90%) after each day were carried forward to the next day of home BP monitoring. RESULTS Of the 361 participants (mean [SD] age of 41.3 [13.2] years; 60.4% women), 38.0% had high home BP during the reference period. There were 63.7%, 17.1%, 10.5%, 3.3%, 3.6%, and 1.4% participants who would not need to continue after 1, 2, 3, 4, 5, and 6 days of monitoring. CONCLUSIONS In most people, high home BP can be identified or excluded with a high degree of confidence with 3 days or less of monitoring.
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Affiliation(s)
- Corey K Bradley
- The Columbia Hypertension Center and Lab, Columbia University Irving Medical Center, New York, New York
| | - Eunhee Choi
- The Columbia Hypertension Center and Lab, Columbia University Irving Medical Center, New York, New York
| | - Marwah Abdalla
- Center for Behavioral Cardiovascular Health, Columbia University Irving Medical Center, New York, New York
| | - Hiroyuki Mizuno
- The Columbia Hypertension Center and Lab, Columbia University Irving Medical Center, New York, New York
- Department of Cardiology, Jichi University School of Medicine, Tochigi, Japan
| | - Michael Lam
- The Columbia Hypertension Center and Lab, Columbia University Irving Medical Center, New York, New York
| | - Maria Cepeda
- The Columbia Hypertension Center and Lab, Columbia University Irving Medical Center, New York, New York
| | - Dona Sangapalaarachchi
- The Columbia Hypertension Center and Lab, Columbia University Irving Medical Center, New York, New York
| | - Justin Liu
- The Columbia Hypertension Center and Lab, Columbia University Irving Medical Center, New York, New York
| | - Paul Muntner
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama
| | - Kazuomi Kario
- Department of Cardiology, Jichi University School of Medicine, Tochigi, Japan
| | - Anthony J Viera
- Department of Family Medicine and Community Health, Duke University School of Medicine, Durham, NC
| | - Joseph E Schwartz
- Center for Behavioral Cardiovascular Health, Columbia University Irving Medical Center, New York, New York
- Department of Psychiatry and Behavioral Sciences, Stony Brook University, Stony Brook, New York
| | - Daichi Shimbo
- The Columbia Hypertension Center and Lab, Columbia University Irving Medical Center, New York, New York
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Arai J, Niikura R, Yamada A, Aoki T, Suzuki N, Tsuji Y, Hayakawa Y, Kawai T, Fujishiro M. The Association between Diverticular Rebleeding and Early-Morning Blood Pressure and Surge: A Prospective Observational Trial. Digestion 2023; 104:400-408. [PMID: 37413970 PMCID: PMC10614272 DOI: 10.1159/000531099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 05/11/2023] [Indexed: 07/08/2023]
Abstract
INTRODUCTION Colonic diverticular bleeding is the major cause of lower gastrointestinal bleeding. Hypertension is a major risk factor for diverticular rebleeding. Direct evidence of an association between actual 24-h blood pressure (BP) and rebleeding is lacking. Therefore, we analyzed the association between 24-h BP and diverticular rebleeding. METHODS We performed a prospective observational cohort trial involving hospitalized patients with colonic diverticular bleeding. We performed 24-h BP measurements (ambulatory BP monitoring [ABPM]) in the patients. The primary outcome was diverticular rebleeding. We evaluated the 24-h BP difference and the morning and pre-awaking BP surge between rebleeding and non-rebleeding patients. Morning BP surge was defined as early-morning systolic BP minus the lowest night systolic BP >45 mm Hg (highest quartile of morning BP surge). The pre-awaking BP surge was defined as the difference between morning BP and pre-awaking BP. RESULTS Of 47 patients, 17 were excluded, leaving 30 who underwent ABPM. Of the 30 patients, 4 (13.33%) had rebleeding. The mean 24-h systolic and diastolic BP were 125.05 and 76.19 mm Hg in rebleeding patients and 129.98 and 81.77 mm Hg in non-rebleeding patients, respectively. Systolic BP at 5:00 (difference -23.53 mm Hg, p = 0.031) and 11:30 (difference -31.48 mm Hg, p = 0.006) was significantly lower in rebleeding patients than in non-rebleeding patients. Diastolic BP at 2:30 (difference -17.75 mm Hg, p = 0.023) and 5:00 (difference -16.12 mm Hg, p = 0.043) was significantly lower in rebleeding patients than in non-rebleeding patients. A morning surge was observed in one rebleeding patient and no non-rebleeding patients. The pre-awaking surge was significantly higher in rebleeding patients (28.44 mm Hg) than in non-rebleeding patients (9.30 mm Hg) (p = 0.015). CONCLUSION Lower BP in the early-morning and a higher pre-awaking surge were risk factors for diverticular rebleeding. A 24-h ABPM can identify these BP findings and reduce the risk of rebleeding by enabling interventions in patients with diverticular bleeding.
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Affiliation(s)
- Junya Arai
- Department of Gastroenterology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan,
- Gastroenterological Endoscopy, Tokyo Medical University, Tokyo, Japan,
| | - Ryota Niikura
- Department of Gastroenterology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
- Department of Gastroenterology, Graduate School of Medicine, Tokyo Medical University, Tokyo, Japan
| | - Atsuo Yamada
- Department of Gastroenterology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Tomonori Aoki
- Department of Gastroenterology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Nobumi Suzuki
- Department of Gastroenterology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Yosuke Tsuji
- Department of Gastroenterology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Yoku Hayakawa
- Department of Gastroenterology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Takashi Kawai
- Department of Gastroenterology, Graduate School of Medicine, Tokyo Medical University, Tokyo, Japan
| | - Mitsuhiro Fujishiro
- Department of Gastroenterology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
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Cepeda M, Pham P, Shimbo D. Status of ambulatory blood pressure monitoring and home blood pressure monitoring for the diagnosis and management of hypertension in the US: an up-to-date review. Hypertens Res 2023; 46:620-629. [PMID: 36604475 PMCID: PMC9813901 DOI: 10.1038/s41440-022-01137-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 11/17/2022] [Accepted: 11/22/2022] [Indexed: 01/06/2023]
Abstract
The diagnosis and management of hypertension has been based on the measurement of blood pressure (BP) in the office setting. However, data have demonstrated that BP may substantially differ when measured in the office than when measured outside the office setting. Higher out-of-office BP is associated with increased cardiovascular risk independent of office BP. Ambulatory BP monitoring (ABPM) and home BP monitoring (HBPM) are validated approaches for out-of-office BP measurement. In the 2015 and 2021 United States Preventive Services Task Force (USPSTF) reports on screening for hypertension, ABPM was recommended as the reference standard for out-of-office BP monitoring and for confirming an initial diagnosis of hypertension. This recommendation was based on data from more published studies of ABPM vs. HBPM on the predictive value of out-of-office BP independent of office BP. Therefore, HBPM was recommended as an alternative approach when ABPM was not available or well tolerated. The 2017 American College of Cardiology (ACC)/American Heart Association (AHA) BP guideline recommended ABPM as the preferred initial approach for detecting white-coat hypertension and masked hypertension among adults not taking antihypertensive medication. In contrast, HBPM was recommended as the preferred initial approach for detecting the white-coat effect and masked uncontrolled hypertension among adults taking antihypertensive medication. The current review provides an overview of ABPM and HBPM in the US, including best practices, BP thresholds that should be used for the diagnosis and treatment of hypertension, barriers to widespread use of such monitoring, US guideline recommendations for ABPM and HBPM, and data supporting HBPM over ABPM.
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Affiliation(s)
- Maria Cepeda
- Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Patrick Pham
- Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Daichi Shimbo
- Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA.
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Glenn TW, Eaton CK, Psoter KJ, Eakin MN, Pruette CS, Riekert KA, Brady TM. Agreement between attended home and ambulatory blood pressure measurements in adolescents with chronic kidney disease. Pediatr Nephrol 2022; 37:2405-2413. [PMID: 35166919 PMCID: PMC9376201 DOI: 10.1007/s00467-022-05479-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Revised: 12/20/2021] [Accepted: 01/24/2022] [Indexed: 10/19/2022]
Abstract
BACKGROUND This study aimed to compare attended home blood pressure (BP) measurements (HBPM) with ambulatory BP monitor (ABPM) readings and examine if level of agreement between measurement modalities differs overall and by subgroup. METHODS This was a secondary analysis of data from a 2-year, multicenter observational study of children 11-19 years (mean 15, SD = 2.7) with chronic kidney disease. Participants had 3 standardized resting oscillometric home BPs taken by staff followed by 24-h ABPM within 2 weeks of home BP. BP indices (measured BP/95%ile BP) were calculated for mean triplicate attended HBPM and mean ABPM measurements. Paired HBPM and ABPM measurements taken during any of 5 study visits were compared using linear regression with robust standard errors. Generalized estimating equation-based logistic regression determined sensitivity, specificity, negative, and positive predictive values with ABPM as the gold standard. Analyses were conducted for the group overall and by subgroup. RESULTS A total of 103 participants contributed 251 paired measurements. Indexed systolic BP did not differ between HBPM and daytime APBM (mean difference - 0.002; 95% CI: - 0.006, 0.003); the difference in indexed diastolic BP was minimal (mean difference - 0.033; 95% CI: - 0.040, - 0.025). Overall agreement between HBPM and 24-h ABPM in identifying abnormal BP was high (81.8%). HBPM had higher sensitivity (87.5%) than specificity (77.4%) and greater negative (89.8%) than positive (73.3%) predictive value, and findings were consistent in subgroups. CONCLUSIONS Attended HBPM may be reasonable for monitoring BP when ABPM is unavailable. The greater accessibility and feasibility of attended HBPM may potentially help improve BP control among at-risk youth. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Trevor W Glenn
- Johns Hopkins University School of Medicine, 5501 Hopkins Bayview Circle, Baltimore, MD, 21224, USA.
| | - Cyd K Eaton
- Johns Hopkins University School of Medicine, Baltimore MD - 733 N Broadway, Baltimore, MD, 21205, USA
| | - Kevin J Psoter
- Johns Hopkins University School of Medicine, Baltimore MD - 733 N Broadway, Baltimore, MD, 21205, USA
| | - Michelle N Eakin
- Johns Hopkins University School of Medicine, Baltimore MD - 733 N Broadway, Baltimore, MD, 21205, USA
| | - Cozumel S Pruette
- Johns Hopkins University School of Medicine, Baltimore MD - 733 N Broadway, Baltimore, MD, 21205, USA
| | - Kristin A Riekert
- Johns Hopkins University School of Medicine, Baltimore MD - 733 N Broadway, Baltimore, MD, 21205, USA
| | - Tammy M Brady
- Johns Hopkins University School of Medicine, Baltimore MD - 733 N Broadway, Baltimore, MD, 21205, USA
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Kim JS, Rhee MY, Kim CH, Kim YR, Do U, Kim JH, Kim YK, Lee HJ, Park JY, Namgung J, Lee SY, Cho DK, Choi TY, Kim SY. Algorithm for diagnosing hypertension using out-of-office blood pressure measurements. J Clin Hypertens (Greenwich) 2021; 23:1965-1974. [PMID: 34699680 PMCID: PMC8630611 DOI: 10.1111/jch.14382] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 10/12/2021] [Accepted: 10/12/2021] [Indexed: 11/27/2022]
Abstract
The authors developed and validated a diagnostic algorithm using the optimal upper and lower cut‐off values of office and home BP at which ambulatory BP measurements need to be applied. Patients presenting with high BP (≥140/90 mm Hg) at the outpatient clinic were referred to measure office, home, and ambulatory BP. Office and home BP were divided into hypertension, intermediate (requiring diagnosis using ambulatory BP), and normotension zones. The upper and lower BP cut‐off levels of intermediate zone were determined corresponding to a level of 95% specificity and 95% sensitivity for detecting daytime ambulatory hypertension by using the receiver operator characteristic curve. A diagnostic algorithm using three methods, OBP‐ABP: office BP measurement and subsequent ambulatory BP measurements if office BP is intermediate zone; OBP‐HBP‐ABP: office BP, subsequent home BP measurement if office BP is within intermediate zone and subsequent ambulatory BP measurement if home BP is within intermediate zone; and HBP‐ABP: home BP measurement and subsequent ambulatory BP measurements if home BP is within intermediate zone, were developed and validated. In the development population (n = 256), the developed algorithm yielded better diagnostic accuracies than 75.8% (95%CI 70.1–80.9) for office BP alone and 76.2% (95%CI 70.5–81.3) for home BP alone as follows: 96.5% (95%CI: 93.4–98.4) for OBP‐ABP, 93.4% (95%CI: 89.6–96.1) for OBP‐HBP‐ABP, and 94.9% (95%CI: 91.5–97.3%) for HBP‐ABP. In the validation population (n = 399), the developed algorithm showed similarly improved diagnostic accuracy. The developed algorithm applying ambulatory BP measurement to the intermediate zone of office and home BP improves the diagnostic accuracy for hypertension.
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Affiliation(s)
- Je Sang Kim
- Cardiovascular Center, Dongguk University Ilsan Hospital, Goyang, South Korea
| | - Moo-Yong Rhee
- Cardiovascular Center, Dongguk University Ilsan Hospital, Goyang, South Korea
| | - Chee Hae Kim
- Cardiovascular Center, Dongguk University Ilsan Hospital, Goyang, South Korea
| | - Yoo Ri Kim
- Cardiovascular Center, Dongguk University Ilsan Hospital, Goyang, South Korea
| | - Ungjeong Do
- Cardiovascular Center, Dongguk University Ilsan Hospital, Goyang, South Korea
| | - Ji-Hyun Kim
- Cardiovascular Center, Dongguk University Ilsan Hospital, Goyang, South Korea
| | - Young Kwon Kim
- Cardiovascular Center, Dongguk University Ilsan Hospital, Goyang, South Korea
| | - Hyun Jung Lee
- Division of Hematology and Medical Oncology, Dongguk University Ilsan Hospital, Goyang, South Korea
| | - Jee Yeon Park
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Goyang, South Korea
| | - June Namgung
- Division of Cardiology, Department of Internal Medicine, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, South Korea
| | - Sung Yun Lee
- Division of Cardiology, Department of Internal Medicine, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, South Korea
| | - Deok-Kyu Cho
- Division of Cardiology, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, South Korea
| | - Tae-Young Choi
- Department of Internal Medicine, Seoul Red Cross Hospital, Seoul, South Korea
| | - Seok Yeon Kim
- Department of Internal Medicine, Seoul Medical Center, Seoul, South Korea
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Constanti M, Boffa R, Floyd CN, Wierzbicki AS, McManus RJ, Glover M. Options for the diagnosis of high blood pressure in primary care: a systematic review and economic model. J Hum Hypertens 2021; 35:455-461. [PMID: 32461579 PMCID: PMC8134050 DOI: 10.1038/s41371-020-0357-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 05/08/2020] [Accepted: 05/13/2020] [Indexed: 02/06/2023]
Abstract
The 2011 NICE hypertension guideline (CG127) undertook a systematic review of the diagnostic accuracy of different blood pressure (BP) assessment methods to confirm the diagnosis of hypertension. The guideline also undertook a cost-utility analysis exploring the cost-effectiveness of the monitoring methods. A new systematic review was undertaken as part of the 2019 NICE hypertension guideline update (NG136). BP monitoring methods compared included Ambulatory BP, Clinic BP and Home BP. Ambulatory BP was the reference standard. The economic model from the 2011 guideline was updated with this new accuracy data. Home BP was more sensitive and specific than Clinic BP. Specificity improved more than sensitivity since the 2011 review. A higher specificity translates into fewer people requiring unnecessary treatment. A key interest was to compare Home BP and Ambulatory BP, and whether any improvement in Home BP accuracy would change the model results. Ambulatory BP remained the most cost-effective option in all age and sex subgroups. In all subgroups, Ambulatory BP was associated with lower costs than Clinic BP and Home BP. In all except one subgroup (females aged 40), Ambulatory BP was dominant. However, Ambulatory BP remained the most cost-effective option in 40-year-old females as the incremental cost-effectiveness ratio for Home BP versus Ambulatory BP was above the NICE £20,000 threshold. The new systematic review showed that the accuracy of both Clinic BP and Home BP has increased. However, Ambulatory BP remains the most cost-effective option to confirm a diagnosis of hypertension in all subgroups evaluated.
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Affiliation(s)
- Margaret Constanti
- National Clinical Guidelines Centre, Royal College of Physicians, London, UK.
| | - Rebecca Boffa
- National Clinical Guidelines Centre, Royal College of Physicians, London, UK
| | | | - Anthony S Wierzbicki
- Department of Metabolic Medicine/Chemical Pathology, Guy's & St Thomas' Hospitals, London, UK
| | - Richard J McManus
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Mark Glover
- The Division of Therapeutics and Molecular Medicine, University of Nottingham, Nottingham, UK
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Karnjanapiboonwong A, Anothaisintawee T, Chaikledkaew U, Dejthevaporn C, Attia J, Thakkinstian A. Diagnostic performance of clinic and home blood pressure measurements compared with ambulatory blood pressure: a systematic review and meta-analysis. BMC Cardiovasc Disord 2020; 20:491. [PMID: 33225900 PMCID: PMC7681982 DOI: 10.1186/s12872-020-01736-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Accepted: 10/09/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Clinic blood pressure measurement (CBPM) is currently the most commonly used form of screening for hypertension, however it might have a problem detecting white coat hypertension (WCHT) and masked hypertension (MHT). Home blood pressure measurement (HBPM) may be an alternative, but its diagnostic performance is inconclusive relative to CBPM. Therefore, this systematic review aimed to estimate the performance of CBPM and HBPM compared with ambulatory blood pressure measurement(ABPM) and to pool prevalence of WCHT and MHT. METHODS Medline, Scopus, Cochrane Central Register of Controlled Trials and WHO's International Clinical Trials Registry Platform databases were searched up to 23rd January 2020. Studies having diagnostic tests as CBPM or HBPM with reference standard as ABPM, reporting sensitivity and specificity of both tests and/or proportion of WCHT or MHT were eligible. Diagnostic performance of CBPM and HBPM were pooled using bivariate mixed-effect regression model. Random effect model was applied to pool prevalence of WCHT and MHT. RESULTS Fifty-eight studies were eligible. Pooled sensitivity, specificity, and diagnostic odds ratio (DOR) of CBPM, when using 24-h ABPM as the reference standard, were 74% (95% CI: 65-82%), 79% (95% CI: 69%, 87%), and 11.11 (95% CI: 6.82, 14.20), respectively. Pooled prevalence of WCHT and MHT were 0.24 (95% CI 0.19, 0.29) and 0.29 (95% CI 0.20, 0.38). Pooled sensitivity, specificity, and DOR of HBPM were 71% (95% CI 61%, 80%), 82% (95% CI 77%, 87%), and 11.60 (95% CI 8.98, 15.13), respectively. CONCLUSIONS Diagnostic performances of HBPM were slightly higher than CBPM. However, the prevalence of MHT was high in negative CBPM and some persons with normal HBPM had elevated BP from 24-h ABPM. Therefore, ABPM is still necessary for confirming the diagnosis of HT.
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Affiliation(s)
| | - Thunyarat Anothaisintawee
- Mahidol University Health Technology Assessment (MUHTA) Graduate Program, Mahidol University, Bangkok, Thailand
- Department of Family Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Rachathevi, Bangkok, 10400 Thailand
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Usa Chaikledkaew
- Mahidol University Health Technology Assessment (MUHTA) Graduate Program, Mahidol University, Bangkok, Thailand
- Social and Administrative Pharmacy Division, Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand
| | - Charungthai Dejthevaporn
- Division of Neurology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - John Attia
- School of Medicine and Public Health, University of Newcastle and Hunter Medical Research Institute, Newcastle, NSW Australia
| | - Ammarin Thakkinstian
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Gill P, Haque MS, Martin U, Mant J, Mohammed MA, Heer G, Johal A, Kaur R, Schwartz C, Wood S, Greenfield SM, McManus RJ. Measurement of blood pressure for the diagnosis and management of hypertension in different ethnic groups: one size fits all. BMC Cardiovasc Disord 2017; 17:55. [PMID: 28178928 PMCID: PMC5299651 DOI: 10.1186/s12872-017-0491-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Accepted: 02/03/2017] [Indexed: 12/11/2022] Open
Abstract
Background Hypertension is a major risk factor for cardiovascular disease and prevalence varies by ethnic group. The diagnosis and management of blood pressure are informed by guidelines largely based on data from white populations. This study addressed whether accuracy of blood pressure measurement in terms of diagnosis of hypertension varies by ethnicity by comparing two measurement modalities (clinic blood pressure and home monitoring) with a reference standard of ambulatory BP monitoring in three ethnic groups. Methods Cross-sectional population study (June 2010 - December 2012) with patients (40–75 years) of white British, South Asian and African Caribbean background with and without a previous diagnosis of hypertension recruited from 28 primary care practices. The study compared the test performance of clinic BP (using various protocols) and home-monitoring (1 week) with a reference standard of mean daytime ambulatory measurements using a threshold of 140/90 mmHg for clinic and 135/85 mmHg for out of office measurement. Results A total of 551 participants had complete data of whom 246 were white British, 147 South Asian and 158 African Caribbean. No consistent difference in accuracy of methods of blood pressure measurement was observed between ethnic groups with or without a prior diagnosis of hypertension: for people without hypertension, clinic measurement using three different methodologies had high specificity (75–97%) but variable sensitivity (33–65%) whereas home monitoring had sensitivity of 68–88% and specificity of 64–80%. For people with hypertension, detection of a raised blood pressure using clinic measurements had sensitivities of 34–69% with specificity of 73–92% and home monitoring had sensitivity (81–88%) and specificity (55–65%). Conclusions For people without hypertension, ABPM remains the choice for diagnosing hypertension compared to the other modes of BP measurement regardless of ethnicity. Differences in accuracy of home monitoring and clinic monitoring (higher sensitivity of the former; higher specificity of the latter) were also not affected by ethnicity. Electronic supplementary material The online version of this article (doi:10.1186/s12872-017-0491-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Paramjit Gill
- Primary Care Clinical Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK.
| | - M Sayeed Haque
- Primary Care Clinical Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Una Martin
- Institute of Clinical Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Jonathan Mant
- Primary Care Unit, University of Cambridge, Cambridge, CB2 0SR, UK
| | | | - Gurdip Heer
- Primary Care Clinical Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Amanpreet Johal
- Primary Care Clinical Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Ramandeep Kaur
- Primary Care Clinical Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Claire Schwartz
- Primary Care Health Sciences, NIHR School for Primary Care Research, University of Oxford, Radcliffe Observatory Quarter, Woodstock Rd, Oxford, OX1 2GG, UK
| | - Sally Wood
- Primary Care Health Sciences, NIHR School for Primary Care Research, University of Oxford, Radcliffe Observatory Quarter, Woodstock Rd, Oxford, OX1 2GG, UK
| | - Sheila M Greenfield
- Primary Care Clinical Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Richard J McManus
- Primary Care Health Sciences, NIHR School for Primary Care Research, University of Oxford, Radcliffe Observatory Quarter, Woodstock Rd, Oxford, OX1 2GG, UK
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Differences in night-time and daytime ambulatory blood pressure when diurnal periods are defined by self-report, fixed-times, and actigraphy: Improving the Detection of Hypertension study. J Hypertens 2016; 34:235-43. [PMID: 26867054 DOI: 10.1097/hjh.0000000000000791] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVES To determine whether defining diurnal periods by self-report, fixed-time, or actigraphy produce different estimates of night-time and daytime ambulatory blood pressure (ABP). METHODS Over a median of 28 days, 330 participants completed two 24-h ABP and actigraphy monitoring periods with sleep diaries. Fixed night-time and daytime periods were defined as 0000-0600 h and 1000-2000 h, respectively. Using the first ABP period, within-individual differences for mean night-time and daytime ABP and kappa statistics for night-time and daytime hypertension (systolic/diastolic ABP≥120/70 mmHg and ≥135/85 mmHg, respectively) were estimated comparing self-report, fixed-time, or actigraphy for defining diurnal periods. Reproducibility of ABP was also estimated. RESULTS Within-individual mean differences in night-time systolic ABP were small, suggesting little bias, when comparing the three approaches used to define diurnal periods. The distribution of differences, represented by 95% confidence intervals (CI), in night-time systolic and diastolic ABP and daytime systolic and diastolic ABP was narrowest for self-report versus actigraphy. For example, mean differences (95% CI) in night-time systolic ABP for self-report versus fixed-time was -0.53 (-6.61, +5.56) mmHg, self-report versus actigraphy was 0.91 (-3.61, +5.43) mmHg, and fixed-time versus actigraphy was 1.43 (-5.59, +8.46) mmHg. Agreement for night-time and daytime hypertension was highest for self-report versus actigraphy: kappa statistic (95% CI) = 0.91 (0.86,0.96) and 1.00 (0.98,1.00), respectively. The reproducibility of mean ABP and hypertension categories was similar using each approach. CONCLUSION Given the high agreement with actigraphy, these data support using self-report to define diurnal periods on ABP monitoring. Further, the use of fixed-time periods may be a reasonable alternative approach.
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Booth JN, Muntner P, Diaz KM, Viera AJ, Bello NA, Schwartz JE, Shimbo D. Evaluation of Criteria to Detect Masked Hypertension. J Clin Hypertens (Greenwich) 2016; 18:1086-1094. [PMID: 27126770 DOI: 10.1111/jch.12830] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Revised: 02/17/2016] [Accepted: 02/22/2016] [Indexed: 11/27/2022]
Abstract
The prevalence of masked hypertension (out-of-clinic daytime systolic/diastolic blood pressure (SBP/DBP) ≥135/85 mm Hg on ambulatory blood pressure monitoring [ABPM] among adults with clinic SBP/DBP <140/90 mm Hg) is high. It is unclear who should be screened for masked hypertension. The authors derived a clinic blood pressure (CBP) index to identify populations for masked hypertension screening. Index cut points corresponding to 75% to 99% sensitivity and prehypertension were evaluated as ABPM testing criterion. In a derivation cohort (n=695), the index was clinic SBP+1.3*clinic DBP. In an external validation cohort (n=675), the sensitivity for masked hypertension using an index ≥190 mm Hg and ≥217 mm Hg and prehypertension status was 98.5%, 71.5%, and 82.5%, respectively. Using National Health and Nutrition Examination Survey data (n=11,778), the authors estimated that these thresholds would refer 118.6, 44.4, and 59.3 million US adults, respectively, to ABPM screening for masked hypertension. In conclusion, the CBP index provides a useful approach to identify candidates for masked hypertension screening using ABPM.
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Affiliation(s)
- John N Booth
- University of Alabama at Birmingham, Birmingham, AL
| | - Paul Muntner
- University of Alabama at Birmingham, Birmingham, AL
| | - Keith M Diaz
- Columbia University Medical Center, New York, NY
| | - Anthony J Viera
- Department of Family Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
| | | | - Joseph E Schwartz
- Columbia University Medical Center, New York, NY.,Department of Psychiatry and Behavioral Sciences, Stony Brook University, Stony Brook, NY
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Stergiou GS, Kollias A, Zeniodi M, Karpettas N, Ntineri A. Home Blood Pressure Monitoring: Primary Role in Hypertension Management. Curr Hypertens Rep 2014; 16:462. [DOI: 10.1007/s11906-014-0462-8] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Kaplan RM, Stone AA. Bringing the laboratory and clinic to the community: mobile technologies for health promotion and disease prevention. Annu Rev Psychol 2012; 64:471-98. [PMID: 22994919 DOI: 10.1146/annurev-psych-113011-143736] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Health-related information collected in psychological laboratories may not be representative of people's everyday health. For at least 70 years, there has been a call for methods that sample experiences from everyday environments and circumstances. New technologies, including cell phones, sensors, and monitors, now make it possible to collect information outside of the laboratory in environments representative of everyday life. We review the role of mobile technologies in the assessment of health-related behaviors, physiological responses, and self-reports. Ecological momentary assessment offers a wide range of new opportunities for ambulatory assessment and evaluation. The value of mobile technologies for interventions to improve health is less well established. Among 21 randomized clinical trials evaluating interventions that used mobile technologies, more than half failed to document significant improvements on health outcomes or health risk factors. Theoretical and practical issues for future research are discussed.
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Affiliation(s)
- Robert M Kaplan
- Office of Behavioral and Social Sciences Research, National Institutes of Health, Bethesda, Maryland 20892-2027, USA.
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Masked hypertension and prehypertension: diagnostic overlap and interrelationships with left ventricular mass: the Masked Hypertension Study. Am J Hypertens 2012; 25:664-71. [PMID: 22378035 DOI: 10.1038/ajh.2012.15] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Masked hypertension (MHT) and prehypertension (PHT) are both associated with an increase in cardiovascular disease (CVD) risk, relative to sustained normotension. This study examined the diagnostic overlap between MHT and PHT, and their interrelationships with left ventricular (LV) mass index (LVMI), a marker of cardiovascular end-organ damage. METHODS A research nurse performed three manual clinic blood pressure (CBP) measurements on three occasions over a 3-week period (total of nine readings, which were averaged) in 813 participants without treated hypertension from the Masked Hypertension Study, an ongoing worksite-based, population study. Twenty-four-hour ambulatory blood pressure (ABP) was assessed by using a SpaceLabs 90207 monitor. LVMI was determined by echocardiography in 784 (96.4%) participants. RESULTS Of the 813 participants, 769 (94.6%) had normal CBP levels (<140/90 mm Hg). One hundred and seventeen (15.2%) participants with normal CBP had MHT (normal CBP and mean awake ABP ≥135/85 mm Hg) and 287 (37.3%) had PHT (mean CBP 120-139/80-89 mm Hg). 83.8% of MHT participants had PHT and 34.1% of PHT participants had MHT. MHT was infrequent (3.9%) when CBP was optimal (<120/80 mm Hg). After adjusting for age, gender, body mass index (BMI), race/ethnicity, history of high cholesterol, history of diabetes, current smoking, family history of hypertension, and physical activity, compared with optimal CBP with MHT participants, LVMI was significantly greater in PHT without MHT participants and in PHT with MHT participants. CONCLUSIONS In this community sample, there was substantial diagnostic overlap between MHT and PHT. The diagnosis of MHT using an ABP monitor may not be warranted for individuals with optimal CBP.
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Muntner P, Levitan EB, Reynolds K, Mann DM, Tonelli M, Oparil S, Shimbo D. Within-visit variability of blood pressure and all-cause and cardiovascular mortality among US adults. J Clin Hypertens (Greenwich) 2012; 14:165-71. [PMID: 22372776 DOI: 10.1111/j.1751-7176.2011.00581.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The association between within-visit variability of systolic blood pressure (SBP) and diastolic blood pressure (DBP) and all-cause and cardiovascular (CVD) mortality was examined using the Third National Health and Nutrition Survey (n=15,317). Three SBP and DBP readings were taken by physicians during a single medical evaluation. Within-visit variability for each participant was defined using the standard deviation of SBP and DBP across these measurements. Mortality was assessed over 14 years (n=3848 and n=1684 deaths from all causes and CVD, respectively). After age, sex, and race-ethnicity adjustment, the hazard ratios (95% confidence intervals) for all-cause mortality associated with the 4 highest quintiles of within-visit standard deviation of SBP (2.00-2.99 mm Hg, 3.00-3.99 mm Hg, 4.00-5.29 mm Hg, and ≥5.30 mm Hg) compared with participants in the lowest quintile of within-visit standard deviation of SBP (<2.0 mm Hg) were 1.04 (0.87-1.26), 1.09 (0.92-1.29), 1.06 (0.88-1.28), and 1.13 (0.95-1.33), respectively (P=.136). The analogous hazard ratios for CVD mortality were 0.95 (0.69-1.32), 0.96 (0.67-1.36), 0.95 (0.74-1.23), and 1.04 (0.80-1.35), respectively (P=.566). No association with mortality was present after further adjustment and when modeling within-visit standard deviation of SBP as a continuous variable. Standard deviation of DBP was not associated with mortality.
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Affiliation(s)
- Paul Muntner
- Department of Epidemiology, University of Alabama at Birmingham, 1665 University Boulevard, Birmingham, AL 35294, USA.
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Hodgkinson J, Mant J, Martin U, Guo B, Hobbs FDR, Deeks JJ, Heneghan C, Roberts N, McManus RJ. Relative effectiveness of clinic and home blood pressure monitoring compared with ambulatory blood pressure monitoring in diagnosis of hypertension: systematic review. BMJ 2011; 342:d3621. [PMID: 21705406 PMCID: PMC3122300 DOI: 10.1136/bmj.d3621] [Citation(s) in RCA: 244] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To determine the relative accuracy of clinic measurements and home blood pressure monitoring compared with ambulatory blood pressure monitoring as a reference standard for the diagnosis of hypertension. DESIGN Systematic review with meta-analysis with hierarchical summary receiver operating characteristic models. Methodological quality was appraised, including evidence of validation of blood pressure measurement equipment. DATA SOURCES Medline (from 1966), Embase (from 1980), Cochrane Database of Systematic Reviews, DARE, Medion, ARIF, and TRIP up to May 2010. Eligibility criteria for selecting studies Eligible studies examined diagnosis of hypertension in adults of all ages using home and/or clinic blood pressure measurement compared with those made using ambulatory monitoring that clearly defined thresholds to diagnose hypertension. RESULTS The 20 eligible studies used various thresholds for the diagnosis of hypertension, and only seven studies (clinic) and three studies (home) could be directly compared with ambulatory monitoring. Compared with ambulatory monitoring thresholds of 135/85 mm Hg, clinic measurements over 140/90 mm Hg had mean sensitivity and specificity of 74.6% (95% confidence interval 60.7% to 84.8%) and 74.6% (47.9% to 90.4%), respectively, whereas home measurements over 135/85 mm Hg had mean sensitivity and specificity of 85.7% (78.0% to 91.0%) and 62.4% (48.0% to 75.0%). CONCLUSIONS Neither clinic nor home measurement had sufficient sensitivity or specificity to be recommended as a single diagnostic test. If ambulatory monitoring is taken as the reference standard, then treatment decisions based on clinic or home blood pressure alone might result in substantial overdiagnosis. Ambulatory monitoring before the start of lifelong drug treatment might lead to more appropriate targeting of treatment, particularly around the diagnostic threshold.
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Affiliation(s)
- J Hodgkinson
- Primary Care Clinical Sciences, University of Birmingham, Edgbaston, Birmingham B15 2PP
| | - J Mant
- General Practice and Primary Care Research Unit, University of Cambridge, Cambridge CB2 0SR
| | - U Martin
- School of Clinical and Experimental Medicine, University of Birmingham, Edgbaston
| | - B Guo
- Public Health, Epidemiology and Biostatistics, University of Birmingham, Edgbaston
| | - F D R Hobbs
- Primary Care Clinical Sciences, University of Birmingham, Edgbaston, Birmingham B15 2PP
| | - J J Deeks
- Public Health, Epidemiology and Biostatistics, University of Birmingham, Edgbaston
| | - C Heneghan
- Department of Primary Health Care, University of Oxford, Headington, Oxford OX3 7LF
| | - N Roberts
- Bodleian Health Care Libraries, Knowledge Centre, ORC Medical Research Building, Oxford OX3 7DQ
| | - R J McManus
- Primary Care Clinical Sciences, University of Birmingham, Edgbaston, Birmingham B15 2PP
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Home blood pressure monitoring in the diagnosis and treatment of hypertension: a systematic review. Am J Hypertens 2011; 24:123-34. [PMID: 20940712 DOI: 10.1038/ajh.2010.194] [Citation(s) in RCA: 122] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND It is recognized that for the reliable assessment of blood pressure (BP) and the accurate diagnosis of hypertension, out-of-office BP measurement with ambulatory (ABPM) or home BP monitoring (HBPM) is often required. The clinical usefulness of ABPM is well established. However, despite the wide use of HBPM, only in the last decade convincing evidence on its usefulness has accumulated. METHODS Systematic review of the evidence on applying HBPM in the diagnosis and treatment of hypertension (PubMed, Cochrane Library, 1970-2010). RESULTS Sixteen studies in untreated and treated subjects assessed the diagnostic ability of HBPM by taking ABPM as reference. Seven randomized studies compared HBPM vs. office measurements or ABPM for treatment adjustment, whereas many studies compared HBPM with office measurements in assessing the antihypertensive drug effects. Several studies with different design investigated the role of HBPM vs. office measurements in improving patients' compliance with treatment and hypertension control rates. The evidence on the cost-effectiveness of HBPM is limited. The studies reviewed consistently showed moderate diagnostic agreement between HBPM and ABPM, and superiority of HBPM compared to office measurements in diagnosing uncontrolled hypertension, assessing antihypertensive drug effects and improving patients' compliance and hypertension control. Preliminary evidence suggests that HBPM has the potential for cost savings. CONCLUSIONS There is conclusive evidence that HBPM is useful for the initial diagnosis and the long-term follow-up of treated hypertension. These data are useful for the optimal application of HBPM, which is widely used in clinical practice. More studies on the cost-effectiveness of HBPM are needed.
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Current world literature. Curr Opin Cardiol 2010; 25:411-21. [PMID: 20535070 DOI: 10.1097/hco.0b013e32833bf995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Algorithms for diagnosing hypertension in the office: translating principle into practice. J Hypertens 2009; 27:1746-7. [DOI: 10.1097/hjh.0b013e32832f343e] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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