Home and Ambulatory Blood Are Tools in Managing Hypertension

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

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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.

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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.

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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