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Dr. Nicolas Roberto Robles
Home blood pressure monitoring holds superior reproducibility and predictive ability in terms of hypertensive target-organ damage and prognosis of cardiovascular disease and also allows for less unnecessary medication use. Review the evidence here.
There is a good relationship between home blood pressure monitoring and cardiovascular prognosis however less evidence supports use clinical decision making. In Spain at least, there are still many cardiologists who give more importance to office blood pressure (OBP) measurements than to HBPM results. This review exposes the reproducibility of this technique, as well as correlation of HBPM with organ damage and long term prognosis.
The measurement of home blood pressure may circumvent a number of observer errors related to measurements in the physician’s office which are subject to:
Ayman and Goldshine (2) were the first to report in 1940 that home blood pressure was less reliable than OBP using HBPM. Nevertheless, this issue could not be adequately addressed until ambulatory blood pressure monitoring (ABPM) with full automatic devices was introduced (3). Superiority of home blood pressure monitoring regarding certain patient outcomes has been made more pressing in the past two decades. Because it offers better correlations with the risk of cardiovascular mortality and target organ damage, the information obtained from home and ambulatory methods reflects more accurately the patient’s risk of future cardiovascular events than does OBP.
A) Cardiovascular mortality
HBPM and ABPM can avoid office-related blood pressure measurement problems and thus put forth information that reflects more accurately the patient’s risk of future cardiovascular events (4,5). In a number of studies, prognostic significance of home systolic BP (SBP) was demonstrated.
B) Target organ damage
Bliziotis et al performed a review and meta-analysis of studies investigating the association of HBPM with target organ damage. A PubMed and Cochrane Library search (1950–2011) pulled 23 studies reporting comparative data of home BP versus ambulatory and/or office measurements and its association with several indices of target organ damage.
Modified from Hara et al. (9)
The use of HBPM for adjusting antihypertensive drug treatment is the object of scarce scientific evidence. The THOP trial however did aim to determine whether or not long-term antihypertensive treatment based on HBPM might be more beneficial to the patient than treatment based on OBP. After a 1-month run-in period, eligible hypertensive patients were randomised into two groups. In one group antihypertensive treatment was guided by the diastolic OBP as an average of three sitting readings obtained by a doctor in the office using a sphygmomanometer and, in the other group, antihypertensive treatment was guided by the diastolic home BP as an average of all 42 sitting readings (3 morning and 3 evening for 7 consecutive days prior to the patient’s visit to the doctor). The patients used the Omron HEM-705CP device (Omron Inc., Kyoto, Japan). Regardless of randomisation, both home and office BP were measured in all patients at each visit. After randomisation, the same standardised stepwise treatment regimen was applied in both groups to reach the same target diastolic BP (80 mm Hg to 89 mm Hg). Four hundred (66%) of the 606 enrolled patients met the entry criteria and were randomised either to office BP (n=197) or home BP (n= 203). At baseline, both the office and home BP groups had similar characteristics and BP values. The median follow-up time was 350 days. Office, home, and ambulatory BP values significantly decreased after randomisation in both treatment groups.After 6 months of treatment, the decreases in BP were similar in the two randomised groups. Thereafter BP reductions became consistently and significantly greater in the office BP patients than in the home BP patients. HBPM allowed the discontinuation of antihypertensive drugs in twice as many patients and thus helped to identify patients with white-coat hypertension. More patients in the HBPM group than in the OBP group were able to permanently stop antihypertensive treatment, but the opposite trend was observed for patients proceeding to multiple drug treatment. In both treatment groups there were similar significant decreases in electrocardiographic indexes of left ventricular mass. From the above, authors concluded that adjustment of antihypertensive treatment based on HBPM instead of OBP led to:
The findings of the THOP trial (10) do not demonstrate that HBPM might be a better guide to antihypertensive drug treatment than conventional OBP measurement but show some comparative benefits.In the same way, the HOMERUS trial (Home Versus Office Measurement, Reduction of Unnecessary Treatment Study) showed that HBPM leads to less medication use than OBP measurement without leading to significant differences in OBP values or target organ damage (11). BP values, however, remain slightly elevated for the HBPM group. Since current clinical guidelines strongly recommended avoid deep decreases of BP (12), this may be an argument favoring HBPM use. Nevertheless, some trials have found the contrary conclusion (13).
The reproducibility of various methods of pressure measurements is challenged by the fact that each tends to define only one aspect of a person's BP:
Historically, the reproducibility of home, clinic, and ambulatory BP was first evaluated by James et al as far as 1988, although previous evidence suggested that among hypertensive patients these may stay about the same or drop over time (17). Authors compared a group of 13 untreated mildly hypertensive subjects with a group of 14 normotensive subjects. Each subject had two sets of daily ambulatory recordings, HBPM readings over 6 days, and clinic measurements taken two weeks apart. Results showed that:
BP readings fall with multiple readings, the extent of which varies according to the interval between successive readings although usually the differences are quite small (19-21). Nonetheless, the differences between triplicates have been sufficient in at least one study for the diagnosis of “hypertension” to be made more frequently with the first than with the mean of the 2nd and 3rd measures (22). On the other hand, some of the guidelines recommend discarding the higher measurements that are often measured initially, but this refinement had no impact in explanatory modelling of cardiovascular risk or organ damage (23).Precision in estimating cardiovascular risk can be expected to increase with the number of measurements for estimation of BP.
Most comparisons between HBSPM and ABPM have been made in order to detect isolated clinic hypertension (white coat hypertension).
On the other hand, less attention has been paid to reproducibility over time of OBP and HBPM.
Home blood pressure monitoring is an inexpensive and convenient method to measure blood pressure in an environment familiar to the patient. The reproducibility of home blood pressure monitoring is comparable to, or even better, than traditional office based blood pressure measurements and it overcomes some biases in office based readings such as digit preference and observer bias. Much evidence has accumulated that shows that HBP is able to predict hypertensive target-organ damage and a prognosis of cardiovascular disease more effectively than OBP and nearly as well as ABPM.
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Nicolas Roberto RoblesCardiovascular Risk InstituteSchool of MedicineUniversidad de SalamancaAddress for mailing: Dr. Nicolás Roberto Robles Pérez-Monteoliva. Unidad de Hipertensión Arterial. Hospital Infanta Cristina. Carretera de Portugal s/n. 06070. Badajoz. Telf. +34924218117. Fax +34924219823.Author's disclosures: None declared.
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