Home and Ambulatory Blood Pressure Measurements Are Essential Tools in Managing Hypertension
Michael A. Weber, MDDivision of Cardiovascular MedicineState University of New York, Downstate Medical Center
The ABPM Device
www.bmj.com/cgi/reprint/322/7285/531.pdf
70
90
110
130
8AM 8PM 8AM
Reproducibility of the Circadian Pattern (Drayer JIM, Weber MA. Am J Med 1982; 493-9, 1982)
Time of Day
Average DBP (mm Hg)
Average SBP (mm Hg)
First 24-hr StudySecond 24-hr Study (n = 56)
24-h Ambulatory Systolic Blood Pressure is a better predictor of clinical outcomes than Office Blood Pressure: USPSTF
USPHS: https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/high‐blood‐pressure‐in‐adults‐screening#fig2
Weber, MA ACP Presentation April, 2018
HR Risk for CVD by ABPM adjusted for office BP
Diagnostic Categories of Blood Pressure
Normal: BP normal in office and at home or elsewhere
Sustained Hypertension: BP high in office, high elsewhere
White coat hypertension: High in office, normal elsewhere
Masked hypertension: BP normal in office, high elsewhere*
* Major CV event rates as high as with sustained hypertension
Prevalence of normal BP, hypertension, white coat hypertension and masked hypertension at 2 office visits 1 week apart as modified by self‐measured BP averaged between the visits in 18,918 previously undiagnosed Indian primary care patients (Kaul U. et al. J Hypertens 2020; 1262‐1270)
A small, inexpensive and validated Home BP Monitor (can also be used in the clinic)
Home Blood Pressure Measurements
• Useful for identifying normal BP/ hypertension/ white coat hypertension/ masked hypertension
• Helpful in improving patients adherence to treatment
Improved Drug Taking After 3 Months of Home BP Measurements in Hypertensive Patients (Jo SH et al. JCH 2019; Vol 20 [In press])
Effects on Office BP of 3 months Home BP Monitoring in Patients Seen in General Hospitals (GH) 0r Local Clinics (LC)(Jo SH et al. JCH 2019; Vol 20, in press)
Is Nighttime BP the Best predictor of CV Events?
A wrist‐cuff device that measures nighttime blood pressures at pre‐set intervals without noise and only minimal awareness
Out-of-Office and Self-Monitoring of BP
COR LOE Recommendation for Out-of-Office and Self-Monitoring of BP
I ASR
Out-of-office BP measurements are recommended to confirm the diagnosis of hypertension and for titration of BP-lowering medication, in conjunction with telehealth counseling or clinical interventions
SR indicates systematic review
Note: Diagnostic office BP should be average of >2 carefully performed readings, performed on each of >2 separate visits
ABPM Highly Recommended in Pediatric Practice by American Pediatrics Association Guidelines
Graphical Abstract
Am J Hypertens, hpab095, https://doi.org/10.1093/ajh/hpab095
Will new technologies make diagnosing and treating hypertension largely an out‐of‐office procedure?
Categories of Hypertension Using Home BP Monitoring in a Japanese Cohort (Fujiwama T et al. JAMA Cardiol 2018; 3:583‐590)
Adjusted 5-Year Risk of CV Death According to Clinic and Ambulatory BP
Adjusted for other covariates.
Dolan E et al. Hypertension. 2005;46:1-6.
3.5
3.0
2.5
2.0
1.5
1.0
0.5
90 110 130 150 170 190 210 230Systolic Blood Pressure, mm Hg
5-Ye
ar R
isk
of C
ardi
ovas
cula
r Dea
th 3.5
3.0
2.5
2.0
1.5
1.0
0.5
50 60 70 80 90 100 110 120Diastolic Blood Pressure, mm Hg
130
Nighttime24-hourDaytimeConventional
Hig
h Ev
enin
g SB
P
J Hum Hypertens . 2019 Sep 4. doi: 10.1038/s41371‐019‐0243‐6. O
Total Mortality CV Events
Adjusted for cohort, sex, age, body mass index, smoking and drinking, cholesterol, history of CV disease, diabetes mellitus, AH treatment, and 24-hour SBP.
Boggia J et al. Lancet. 2007;370:1219-1229.
1010
Years of Follow-Up
8
6
4
2
0
0 2 4 6 8 10
8
6
4
2
0
0 2 4 6 8 10
P<.0001
Inci
denc
e (%
)
P<.0001
≥1.0
≥0.9–1.0≥0.8–0.9<0.8
IDACO Total Mortality and CV Events by Category of the Night:Day Ratio of SBPTotal Mortality and CV Events by Category of the Night:Day Ratio of SBP
Framingham Heart Study: Characteristics of Heart rate QuartilesHo JE et al. J Am Heart Assoc 2020 doi: 10.1161/JAHA.113.000668
Patient Adherence and BP Control: Effects of 3 Months of Home BP Monitoring
• 7751 patients, 3827 from hospital practices and 3924 from local practices
• BP carefully measured by clinicians immediately before and after the 3 month period
• Patients told to measure BP within 10 minutes of awakening and just before going to bed
• Patients told their BP targets: < 140/90 mmHg if no CV history, < 130/80 mmHg if positive CV history
• All patients provided with Omron BP devices
Jo SH et al. JCH 2019;Vol 20, in press.
Framingham: Quartiles of Heart Rate and Incidence of CV Disease and Heart FailureHo JE et al. J Am Heart Assoc 2020 doi: 10.1161/JAHA.113.000668