Published online before print March 14, 2005, doi: 10.1161/01.HYP.0000160403.89029.31
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(Hypertension. 2005;45:483.)
© 2005 American Heart Association, Inc.
Editorial Commentaries |
Ambulatory Blood Pressure Monitoring for Routine Clinical Practice
From the Division of Cardiology, Sunnybrook & Women’s College Health Sciences Centre and Department of Medicine, University of Toronto, Canada.
Correspondence to Dr Martin G. Myers, Sunnybrook & Women’s College Health Sciences Centre, A-202, 2075 Bayview Avenue, Toronto, Ontario M4N 3M5, Canada. E-mail martin.myers{at}swchsc.on.ca
"The inherent variability of the blood pressure has led to problems in the diagnosis, treatment, and prognosis of hypertension. Knowing how the blood pressure fluctuates with the stresses and strains of everyday life should help in assessing the severity of hypertension, the response to treatment, and the prognosis in individual cases."— —Hinman et al; 1962.
It has taken 40 years for the ideas first proposed in this quote from an article1 on a new portable device for recording blood pressure (BP) to be considered for routine clinical practice. However, it did not take this long for astute researchers to recognize the importance of the development of this portable BP recorder, later known by the name of its manufacturer, the Remler Company.
By 1966, Maurice Sokolow et al had used the semi-automated Remler device to compare casual office BP with readings taken during awake hours in 124 patients with a diagnosis of hypertension.2 Despite the rather primitive technology by today’s standards, Sokolow et al were able to show that the ambulatory BP was a better predictor of hypertensive complications than the casual office BP. Sokolow and colleagues followed-up on this initial observation with a prospective observational study3 comparing the predictive power of the standard office BP versus the Remler device in 1076 patients with essential hypertension for cardiovascular outcomes over a mean 5-year period. This second study confirmed their original observations that ambulatory BP monitoring (ABPM) was a more accurate predictor of outcome than the office BP.
After the publication of these remarkable results, it took more than a decade before more sophisticated, fully automated recording devices made it possible to perform 24-hour ABPM in routine clinical practice. However, clinicians seemed reluctant to accept ABPM, possibly because the publications of Sokolow et al represented the only evidence demonstrating the superiority of ABPM for diagnosing hypertension and predicting its complications compared with the standard office BP as recorded by mercury sphygmomanometer.
Today, there can be no doubt that 24-hour ABPM is a better method for diagnosing hypertension and predicting its cardiovascular risk, with at least 10 studies providing evidence to support this belief.4–13 In each instance, the 24-hour ambulatory BP was able to predict those patients at higher risk for experiencing a cardiovascular event with greater precision than did the office BP. One of the limitations of these studies was that the sample population was generally composed of hypertensive patients and may not have been representative of the general population. Exceptions include the Ohasama study,5,9 which followed-up 1542 men and women residing in Japan, and a Swedish study12 involving 578 men living in the city of Uppsala.
The present report by Hansen et al14 extends the generalizability of these results further by demonstrating the benefits of ABPM in predicting cardiovascular outcome in men and women in a general population of 1700 individuals residing in an urban European center. These authors noted that only ABPM and not office BP was a significant predictor of all-cause and cardiovascular mortality during a mean follow-up period of 9.5 years.
These findings are noteworthy in that they come at a time when 24-hour ABPM is being welcomed as having an important role to play in the diagnosis of hypertension. Medicare and Medicaid recently acknowledged the advantages of 24-hour ABPM over the office BP by approving funding for this procedure in patients suspected of having white-coat hypertension. The recent report from the Subcommittee of Professional and Public Education of the American Heart Association Council on High Blood Pressure Research15 highlights the importance of using out-of-office measures of BP in making a diagnosis of hypertension. In addition, virtually all national and international guidelines for the diagnosis and treatment of hypertension at least mention 24-hour ABPM, noting its superiority over the office BP in diagnosing hypertension.
Despite the evidence provided by the current report of Hansen et al14 and other publications,4–13 it is somewhat surprising that 24-hour ABPM has still not become an integral step in making a diagnosis of hypertension. None of the major hypertension guidelines has included ABPM in algorithms for diagnosing hypertension, leaving the role of ABPM to be discussed in a separate paragraph/section elsewhere in each guideline monograph.
The Canadian Hypertension Education Program (CHEP) in the 2005 revision of its recommendations for the diagnosis and treatment of hypertension16 has decided to recommend 24-hour ABPM and self (home)-BP monitoring as options for making a diagnosis in patients with uncomplicated mild to moderate essential hypertension initially detected by routine office readings. Using an evidence-based approach, the CHEP Task Force concluded that there were sufficient data available to recommend a greater use of ABPM and self-BP monitoring in routine clinical practice. In addition, inclusion of ABPM and self-BP monitoring into the main diagnostic algorithm would facilitate a more rapid diagnosis of hypertension and reduce the risks of having patients being left untreated for prolonged periods while a diagnosis of hypertension was being made using repeated office readings.
Resistance to abandoning the mercury sphygmomanometer as the gold standard for diagnosis hypertension has been quite remarkable. One can only hope that reports such as that of Hansen et al14 will finally lead to the inclusion of 24-hour ABPM into the diagnostic algorithm in all national and international guidelines for managing hypertension. Only then will the prescient conclusions made by Sokolow et al2 almost 40 years ago have received appropriate recognition:
"Portable recorder measurements should aide in selecting patients likely to benefit from antihypertensive therapy and in guiding such treatment."
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Footnotes |
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The opinions expressed in this editorial are not necessarily those of the editors or of the American Heart Association.
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References |
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 Top References |
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- Sokolow M, Werdegar D, Kain HK, Hinman AT. Relationship between level of blood pressure measured casually and by portable recorders and severity of complications in essential hypertension. Circulation. 1966; 34: 279–298.
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[Abstract/Free Full Text] - Ohkubo T, Hozawa A, Nagai K, Kikuya M, Tsuji I, Ito S, Satoh H, Hisamichi S, Imai Y. Prediction of stroke by ambulatory blood pressure monitoring versus screening blood pressure measurements in a general population: the Ohasama study. J Hypertens. 2000; 18: 847–854.[CrossRef][Medline] [Order article via Infotrieve]
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[Abstract/Free Full Text] - Clement DL, De Buyzere ML, De Bacquer DA, de Leeuw PW, Duprez DA, Fagard RH, Gheeraert PJ, Missault LH, Braun JJ, Six RO, Van Der Niepen P, O’Brien E, for the Office versus Ambulatory Pressure Study Investigators. Prognostic value of ambulatory blood-pressure recordings in patients with treated hypertension. N Engl J Med. 2003; 348: 2407–2415.
[Abstract/Free Full Text] - Björklund K, Lind L, Zethelius B, Andrén B, Lithell H. Isolated ambulatory hypertension predicts cardiovascular morbidity in elderly men. Circulation. 2003; 107: 1297–1302.
[Abstract/Free Full Text] - Pierdomenico SD, Lapenna D, Bucci A, Di Iorio A, Neri M, Cuccurullo F, Mezzetti A. Cardiovascular and renal events in uncomplicated mild hypertensive patients with sustained and white coat hypertension. Am J Hypertens. 2004; 17: 876–881.[Medline] [Order article via Infotrieve]
- Hansen TW, Jeppesen J, Rasmussen S, Ibsen H, Torp-Pedersen C. Ambulatory blood pressure and mortality: a population based study. Hypertension. 2005; 45: 499–504.
[Abstract/Free Full Text] - Pickering TG, Hall JE, Appel LJ, Falkner BE, Graves J, Hill MN, Jones DW, Kurtz T, Sheps SG, Roccella EJ. Recommendations for blood pressure measurement in humans and experimental animals Part 1:Blood pressure measurement in humans a statement for professionals from the subcommittee of Professional and Public Education of the Am Heart Association Council on High Blood Pressure Research. Hypertension. 2005; 45: 142–161.
[Abstract/Free Full Text] - Hemmelgarn BR, McAlister FA, Myers MG, McKay DW, Bolli P, Abbott C, Schiffrin EL, Grover S, Honos G, Lebel M, Mann K, Wilson T, Penner B, Tremblay G, for the Canadian Hypertension Education Program. The 2005 Canadian Hypertension Education Program (CHEP) recommendations for the management of hypertension : Part 1-Blood pressure measurement, diagnosis and assessment of risk. Can J Cardiol. 2005. In press.
Related Article:
- Ambulatory Blood Pressure and Mortality: A Population-Based Study
- Tine Willum Hansen, Jørgen Jeppesen, Susanne Rasmussen, Hans Ibsen, and Christian Torp-Pedersen
Hypertension 2005 45: 499-504.[Abstract] [Full Text] [PDF]
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