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Hypertension. 2007;49:17-18
Published online before print November 6, 2006, doi: 10.1161/01.HYP.0000250560.27738.72
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(Hypertension. 2007;49:17.)
© 2007 American Heart Association, Inc.

Editorial Commentaries

Effective Ambulatory Blood Pressure Control in Medical Practice

Good News To Be Taken With Caution

Giuseppe Mancia

From the Clinica Medica, Dipartimento di Medicina Clinica e Prevenzione and Dipartimento di Statistica, Università Milano-Bicocca, Ospedale San Gerardo, Monza (Milan); Istituto Auxologico Italiano, Milan, Italy and Centro Interuniversitario di Fisiologia Clinica e Ipertensione, Università di Milano, Milano-Bicocca and Pavia, Italy.

Correspondence to Giuseppe Mancia, Clinica Medica, Ospedale San Gerardo, Via Pergolesi 33, 20052 Monza, Milan, Italy. E-mail giuseppe.mancia{at}unimib.it

A large number of studies has addressed the question of how effective is blood pressure (BP) control in the hypertensive population,1–3 with a consistent and unequivocal answer. That is, BP control is disappointingly low, because only a small fraction of patients diagnosed as having a BP elevation show on-treatment BPs <140 mm Hg systolic and 90 mm Hg diastolic, which are the target values for treatment recommended by international guidelines.4,5 This is the case regardless of whether patients are followed by general practitioners or specialists6,7 and have a low or high cardiovascular risk profile,8–10 the latter condition making the need of BP control even more compelling given the imminent risk of a cardiovascular event. Reality is obviously even worse when the lower BP targets that have been shown to be additionally protective in high-risk hypertensive patients, that is, <130/80 mm Hg, are considered.4,5 In a recent study performed in Italy, for example, we have shown that in diabetic (and, thus, high risk) hypertensive patients followed by general practitioners, an on-treatment BP <130/80 mm Hg was achieved in only 3% of the sample,7 the conclusion being that in the clinical practice these targets are, at present, no more than a "mirage."

Evidence is available that hypertensive patients in whom BP is uncontrolled by treatment have a cardiovascular risk only modestly less than that of untreated individuals,11 possibly also because in several instances treated BP levels remain quite high, that is, patients are frequently not barely but badly uncontrolled.6,7,9,12 This has led scientific societies involved in hypertension and cardiovascular prevention to consider a substantial increase of BP control in the hypertensive population as a public health goal even more important to pursue than that of discovering new treatments via scientific studies. In this context, the article of Banegas et al13 published in this issue of Hypertension is good news. This is because although office BP was controlled in only 23.6% of the 12 897 hypertensive patients treated by Spanish primary care centers (a figure in line with the low rate reported in other studies), control of daytime BP values was found to be adequate in 51.6% of the cases, that is, a percentage >2 times as large. The authors concluded that in a considerable number of treated hypertensive patients in whom BP measured by the physician remains high, daily life BPs are within the normal reference range, suggesting that the BP elevation found in the clinic environment may be a transient phenomenon (eg, a white-coat effect) and giving the problem of low BP control a more optimistic perspective.

The article by Banegas et al13 has several merits that make its conclusions reliable. First, I am not aware of any other study that has examined BP control not only by office but also by a much more complex method, such as ambulatory BP monitoring, in such a large number of patients. Furthermore, selection of patients and physicians was such as to truly reflect the state of hypertension management in the country involved. Finally, the technical requirements for acceptance of ambulatory BP monitorings were such as to make the data quality adequate, a task particularly difficult to achieve in the clinical practice setting. Some considerations, however, may limit the optimistic implications of these results for BP control in the clinical practice. First, although ambulatory BP was recorded for 24 hours, data on nighttime BP values were not reported, which keeps open the possibility that in some subjects in which daytime BP was controlled, nighttime values remained above their normal limits. This may be clinically relevant, because night BP is prognostically important and its relationship with cardiovascular outcome steeper than that of daytime values.14–16 Second, the pattern characterized by an elevated office and a normal ambulatory BP may have preceded treatment because of the high prevalence (≤30%), in the untreated hypertensive population, of white-coat or isolated office hypertension.17 In other words, in at least part of the treated subjects of the study, the greater rate of ambulatory BP normality could have been present before the therapeutic intervention rather than resulting from it. Finally, there is evidence that individuals in whom ambulatory BP is normal but office BP is elevated are at greater cardiovascular risk than those in which ambulatory and office BPs are both normal.18–20 Indeed, analysis of the data obtained in the Pressioni Arteriose Monitorate E Loro Associazioni (PAMELA) population shows that, compared with subjects in whom office, home, and 24-hour BPs are all normal, the 12-year rate of cardiovascular death was progressively greater when 1, 2, or all 3 of these BPs were elevated (Figure),19 the differences occurring also after adjustment for between-group discrepancies in age and gender. This supports the clinical importance of the data obtained by Banegas et al,13 because patients with an increased office BP and a normal ambulatory BP appear to be at lower risk than those in whom also ambulatory BP is elevated. It also emphasizes, however, that an uncontrolled office BP is associated with a higher-than-optimal risk and that the ideal treatment should control both "in-office" and "out-of-office" BPs.


Figure 1
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  		Incidence of cardiovascular fatal events in subjects of the PAMELA population sample (n=2051) followed for 148 months. Data are shown for subjects in whom: (1) clinic, home, and ambulatory BP values were all normal; (2) 1 or 2 BPs were elevated regardless whether the elevation involved clinic, home, or ambulatory values; and (3) all 3 BPs were elevated before (left) and after (right) adjustment for differences in age and gender. P values refer to trend. Data from Reference 19.


*    Acknowledgments
 
Disclosures

None.


*    Footnotes
 
The opinions expressed in this editorial are not necessarily those of the editors or of the American Heart Association.


*    References
up arrowTop
 *References
 

  1. Kearney PM, Whelton M, Reynolds K, Whelton PK, He J. Worldwide prevalence of hypertension: a systematic review. J Hypertens. 2004; 22: 11–19.[Medline] [Order article via Infotrieve]
  2. Primatesta P, Brookes M, Poulter NR. Improved hypertension management and control: results from the health survey for England 1998. Hypertension. 2001; 38: 827–832.[Abstract/Free Full Text]
  3. Mancia G, Grassi G. Rationale for the use of fixed combination in the treatment of hypertension. Eur Heart J. 1999; 1 (suppl): L14–L19.
  4. Guidelines Committee. 2003 European Society of Hypertension-European Society of Cardiology guidelines for the management of arterial hypertension. J Hypertens. 2003; 21: 1011–1053.[CrossRef][Medline] [Order article via Infotrieve]
  5. Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL, Jr, Jones DW, Materson BJ, Oparil S, Wright JT Jr, Roccella EJ and the National High Blood Pressure Education Program Coordinating Committee. Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension. 2003; 42: 1206–1252.[Abstract/Free Full Text]
  6. Mancia G, Ambrosioni E, Rosei EA, Leonetti G, Trimarco B, Volpe M. Blood pressure control and risk of stroke in untreated and treated hypertensive patients screened from clinical practice: results of the For Life Study. J Hypertens. 2005; 23: 1575–1581.[Medline] [Order article via Infotrieve]
  7. Mancia G, Volpe R, Boros S, Ilardi M, Giannattasio C. Cardiovascular risk profile and blood pressure control in Italian hypertensive patients under specialist care. J Hypertens. 2004; 22: 51–57.[CrossRef][Medline] [Order article via Infotrieve]
  8. Majernick TG, Zacker C, Madden NA, Belletti DA, Arcona S. Correlates of hypertension control in a primary care setting. Am J Hypertens. 2004; 17: 915–920.[CrossRef][Medline] [Order article via Infotrieve]
  9. Mancia G, Pessina AC, Trimarco B, Grassi G. Blood pressure control according to new guidelines targets in low- to high-risk hypertensives managed in specialist practice. J Hypertens. 2004; 22: 2387–2396.[CrossRef][Medline] [Order article via Infotrieve]
  10. EUROASPIRE II Study Group. Lifestyle and risk factor management and use of drug therapies in coronary patients from 15 countries; principal results from EUROASPIRE II Euro Heart Survey Programme. Eur Heart J. 2001; 22: 554–572.[Abstract/Free Full Text]
  11. Benetos A, Thomas F, Bean KE, Guize L. Why cardiovascular mortality is higher in treated hypertensives versus subjects of the same age, in the general population. J Hypertens. 2003; 21: 1635–1640.[CrossRef][Medline] [Order article via Infotrieve]
  12. Burt VL, Cutler JA, Higgins M, Horan MJ, Labarthe D, Whelton P, Brown C, Roccella EJ. Trends in the prevalence, awareness, treatment, and control of hypertension in the adult US population. Data from the health examination surveys, 1960 to 1991. Hypertension. 1995; 26: 60–69.[Abstract/Free Full Text]
  13. Banegas JR, Segura J, Sobrino J, Rodriguez-Artalejo F, de la Sierra A, de la Cruz JJ, Gorostidi M, Sarría A, Ruilope LM. for the Spanish Society of Hypertension Ambulatory Blood Pressure Monitoring Registry Investigators. Effectiveness of blood pressure control outside the medical setting. Hypertension. 2007; 49: 62–68.[Abstract/Free Full Text]
  14. Sega R, Facchetti R, Bombelli M, Cesana G, Corrao G, Grassi G, Mancia G. Prognostic value of ambulatory and home blood pressures compared with office blood pressure in the general population: follow-up results from the Pressioni Arteriose Monitorate e Loro Associazioni (PAMELA) study. Circulation. 2005; 111: 1777–1783.[Abstract/Free Full Text]
  15. Staessen JA, Thijs L, Fagard R, O’Brien ET, Clement D, de Leeuw PW, Mancia G, Nachev C, Palatini P, Parati G, Tuomilehto J, Webster J. Predicting cardiovascular risk using conventional vs ambulatory blood pressure in older patients with systolic hypertension. Systolic Hypertension in Europe Trial Investigators. JAMA. 1999; 282: 539–546.[Abstract/Free Full Text]
  16. Kario K, Pickering TG. White-coat hypertension or white-coat hypertension syndrome: which is accompanied by target organ damage? Arch Intern Med. 2000; 160: 3497–3498.[Free Full Text]
  17. Pickering TG, Coats A, Mallion JM, Mancia G, Verdecchia P. Blood Pressure Monitoring Task Force V: White-coat hypertension. Blood Press Monit. 1999; 4: 333–341.[Medline] [Order article via Infotrieve]
  18. Gustavsen PH, Hoegholm A, Bang LE, Kristensen KS. White-coat hypertension is a cardiovascular risk factor: a 10-year follow-up study. J Hum Hypertens. 2003; 17: 811–817.[CrossRef][Medline] [Order article via Infotrieve]
  19. Mancia G, Facchetti R, Bombelli M, Grassi G, Sega R. Long-term risk of mortality associated with selective and combined elevation in office, home, and ambulatory blood pressure. Hypertension. 2006; 47: 846–853.[Abstract/Free Full Text]
  20. Verdecchia P, Reboldi GP, Angeli F, Schillaci G, Schwartz JE, Pickering TG, Imai Y, Ohkubo T, Kario K. Short- and long-term incidence of stroke in white-coat hypertension. Hypertension. 2005; 45: 203–208.[Abstract/Free Full Text]

Related Article:

Effectiveness of Blood Pressure Control Outside the Medical Setting
José R. Banegas, Julián Segura, Javier Sobrino, Fernando Rodríguez-Artalejo, Alejandro de la Sierra, Juan J. de la Cruz, Manuel Gorostidi, Antonio Sarría, Luis M. Ruilope for the Spanish Society of Hypertension Ambulatory Blood Pressure Monitoring Registry Investigators
Hypertension 2007 49: 62-68. [Abstract] [Full Text] [PDF]



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