Ambulatory Blood Pressure Monitoring and Blood Pressure Self-Measurement in the Diagnosis and Management of Hypertension

doi:10.1059/0003-4819-118-11-199306010-00008

Ambulatory Blood Pressure Monitoring and Blood Pressure Self-Measurement in the Diagnosis and Management of Hypertension

Lawrence J. Appel, MD, MPH; and
William B. Stason, MD, MS

From The Johns Hopkins University School of Medicine, Baltimore, Maryland, and Harvard School of Public Health, Boston, Massachusetts. Requests for Reprints: Lawrence J. Appel, MD, MPH, Welch Center for Prevention, Epidemiology & Clinical Research, The Johns Hopkins Hospital, Carnegie 291, 600 North Wolfe Street, Baltimore MD 21287-6231. Acknowledgments: The authors thank members and staff of the Clinical Efficacy Assessment Subcommittee of the American College of Physicians (Dr. Harold Sox, Chair; Dr. Anne-Marie Audet, Dr. Philip Gold, Dr. Edward Huth, Dr. Ernest Mazzaferri, Dr. Albert Mulley, Dr. George Thibault, and Ms. Linda Johnson White, as well as reviewers of this paper [Dr. Henry Black, Dr. Richard Grimm, Dr. R. Brian Haynes, Dr. Michael Horan, Dr. Stevo Julius, Mr. Dennis Larsen, Dr. Martin Meyers, Dr. Marvin Moser, Dr. H. Mitchel Perry, Dr. Richard Reeves, Dr. Sheldon Sheps, Dr. W. McFate Smith, Dr. Donald Vidt, Dr. Michael Weber, and Dr. William White] for their time, effort, and insight. The authors also thank Ms. Patricia Ann Coleman for manuscript preparation. Grant support: By a Clinician Scientist Award from The Johns Hopkins University School of Medicine; a Clinical Investigator Award (K08HL02642) from the National Heart, Lung, and Blood Institute; and a Health of the Public Grant from The Pew Charitable Trust and the Rockefeller Foundation.

Abstract

Objective: To review published evidence on the use of ambulatory and self-measurement devices in the diagnosis and management of hypertension.

Data Sources: Computerized literature searches and manual review of bibliographies.

Study Selection: Articles documenting original research pertaining to the diagnosis, treatment, or prognosis of hypertension using ambulatory or self-measurement devices.

Results: Studies that have compared office, self-measured, and ambulatory blood pressures have documented substantial, but nonsystematic, differences. Such findings have raised concern over the appropriateness of diagnosing hypertension and initiating drug therapy in individuals with high office blood pressure but comparatively low self-measured or ambulatory blood pressure (office or white coat hypertension). Evidence from a large number of cross-sectional studies and a single prospective study suggests that blood pressure- related end-organ damage is more closely associated with ambulatory than with office blood pressure. Less evidence supports self-measured blood pressure in this regard, and data are insufficient to compare ambulatory and self-measured blood pressure in terms of cardiovascular disease risk prediction. The estimated resource cost of an ambulatory blood pressure test is approximately $120, whereas charges range from $100 to $450. The annualized resource cost of blood pressure self-measurement is $50 or less. On a national level, the annual direct costs of ambulatory blood pressure monitoring could be as high as $6 billion, if this technique were used routinely to diagnose and monitor hypertensive patients. The extent to which direct costs would be offset by savings from less frequent or more efficient treatment for hypertension cannot be estimated reliably. Several practical and technical issues also detract from the potential usefulness of ambulatory and self-measurement devices. Finally, there is some evidence that office blood pressures measured by well-trained nonphysicians may serve as an alternative to ambulatory and self-measurement techniques in estimating usual blood pressure.

Conclusion: Limited clinical applications of ambulatory blood pressure monitoring and blood pressure self-measurement in the diagnosis and management of hypertension appear to be warranted. Endorsement of these technologies for routine clinical use, however, will require more convincing evidence of their clinical effectiveness.