American Heart Association’s Statement That “In Children Ambulatory Blood Pressure Is Superior to Home” Not Proven
To the Editor:
The recent American Heart Association recommendations for ambulatory blood pressure monitoring (ABPM) in children1 failed to give updated guidance to physicians on the alternative method for out-of-office blood pressure measurement, namely, home monitoring (HBPM).
Although in this statement evidence on HBPM in adults has been repeatedly cited,1 2 major position HBPM articles have not been mentioned, probably because they were published when the statement was in press. First is an American Heart Association and American Society of Hypertension joint statement titled, “Call to Action on Use and Reimbursement for HBPM,”2 and, second, the “European Society of Hypertension HBPM Guidelines,”3 both taking strong position in favor of HBPM. Furthermore, the American Heart Association statement1 did not acknowledge the fact that some major trials showing masked hypertension to be associated with increased cardiovascular risk have been based on HBPM.
Evidence on the usefulness of HBPM in children is accumulating. The ABPM reference values have been based on a cross-sectional database of 949 subjects aged 5 to 20 years.4 Reference values for HBPM have also been published, based on a slightly smaller cross-sectional study but with narrower age range (778 subjects 6 to 18 years).6 Studies have shown that the reproducibility of HBPM in children and adolescents is superior to that of office measurements and as good as that of ABPM. A recent study showed that the HBPM schedule proposed by American and European guidelines for adults2,3 is also reliable in children. Furthermore, as for ABPM, some oscillometric arm devices for HBPM validated in adults appear to also be accurate in children.
Indeed, the evidence on the clinical application of HBPM in children is limited. The only study mentioned in the American Heart Association statement1 that investigated the diagnostic ability of HBPM in children6 included subjects with chronic renal failure, HBPM was optionally performed, only 3 readings were regarded as sufficient, and a monitor not recommended in children was used. Thus, the diagnostic potential of HBPM was not exhausted. A similar study in 102 children and adolescents found clinically important disagreement between HBPM and ABPM in the diagnosis of hypertension in only 8% of cases and concluded that the 2 methods are interchangeable.7 By taking ABPM as reference method, the diagnostic value of HBPM was similar to that in the adults.7 Last, it should be mentioned that “self-measurement of home blood pressure” is a misnomer of HBPM, because, in children, measurements are usually taken by their parents.
It is important to acknowledge that HBPM is currently being used by >70% of pediatric nephrologists, as suggested by surveys in the United States, Canada, and Germany. Thus, HBPM has considerable potential in pediatric hypertension. More research on its clinical application and guidance to physicians is urgently needed.
Urbina E, Alpert B, Flynn J, Hayman L, Harshfield GA, Jacobson M, Mahoney L, McCrindle B, Mietus-Snyder M, Steinberger J, Daniels S. American Heart Association Atherosclerosis, Hypertension, and Obesity in Youth Committee. Ambulatory blood pressure monitoring in children and adolescents: recommendations for standard assessment: a scientific statement from the American Heart Association Atherosclerosis, Hypertension, and Obesity in Youth Committee of the Council on Cardiovascular Disease in the Young and the Council for High Blood Pressure Research. Hypertension. 2008; 52: 433–451.
Pickering TG, Miller NH, Ogedegbe G, Krakoff LR, Artinian NT, Goff D; American Heart Association; American Society of Hypertension; Preventive Cardiovascular Nurses Association. Call to action on use and reimbursement for home blood pressure monitoring: executive summary: a joint scientific statement from the American Heart Association. American Society of Hypertension, and Preventive Cardiovascular Nurses Association. Hypertension. 2008; 52: 1–9.
Parati G, Stergiou GS, Asmar R, Bilo G, de Leeuw P, Imai Y, Kario K, Lurbe E, Manolis A, Mengden T, O'Brien E, Ohkubo T, Padfield P, Palatini P, Pickering T, Redon J, Revera M, Ruilope LM, Shennan A, Staessen JA, Tisler A, Waeber B, Zanchetti A, Mancia G; ESH Working Group on Blood Pressure Monitoring, European Society of Hypertension guidelines for blood pressure monitoring at home: a summary report of the Second International Consensus Conference on Home Blood Pressure Monitoring. J Hypertens. 2008; 26: 1505–1526.