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Editor's Note
August 6, 2019

Effective Use of Ambulatory Blood Pressure Monitoring

Author Affiliations
  • 1Departments of Preventive Medicine and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
  • 2Senior Editor, JAMA
JAMA. 2019;322(5):420-421. doi:10.1001/jama.2019.10123

For almost 100 years, higher levels of blood pressure (BP) have been recognized as critically important risk factors for clinical disorders of the cardiovascular systems, brain, and kidney.1 With numerous effective lifestyle and drug treatments available and with clinical trials that convincingly showed the benefits of BP lowering in appropriately selected patients, it is now widely recommended that BP measurement be a routine part of general health screening.1-6 Evidence favoring the use of ambulatory BP monitoring (ABPM) for measurement of BP has accumulated and guidelines now refer to ABPM as the “best out-of-office measurement method.”1 In addition, the Centers for Medicare & Medicaid Services (CMS) recently proposed to pay for expanded use of ABPM for detection of suspected “white coat” hypertension and detection of masked hypertension.7

Ambulatory BP monitoring is used to obtain out-of-office BP readings at established intervals, usually every 15 to 30 minutes over a period of at least 24 hours. A systematic review conducted by the US Preventive Services Task Force8 concluded that ABPM provided a better method to predict long-term cardiovascular disease outcomes than did office BP measurements. Therefore, as described in the article by Yang and colleagues,9 ABPM is considered a preferred method for BP assessment in North American, European, Japanese, and Chinese guidelines.1-6 However, because ABPM monitoring generates a much larger volume of data than other types of BP measurement, including nighttime BP measurements, it has been uncertain which BP index, or indexes, are more strongly associated with adverse health outcomes. The goal of the study by Yang et al9 was to examine data from numerous sources to address this clinically important question.

Using a rigorous assessment of ABPM in more than 11 000 adults, higher 24-hour and nighttime BP were significantly associated with greater risks of death and a cardiovascular outcome, consisting of cardiovascular mortality combined with nonfatal coronary events, heart failure, and stroke. The association persisted after adjusting for other office-based or ambulatory monitoring–derived BP measurements, all of which were also associated with the adverse outcomes. This is important information for patients and clinicians as they determine how to use the large amount of BP data from ABPM. Based on these findings, it is reasonable to consider the 2 most clinically relevant measurements from ABPM to be the 24-hour BP and the nighttime BP. Either could be used to justify treatment of BP that is above the treatment threshold. Most important is to obtain accurate measurement from every patient and to initiate and monitor treatment when indicated.

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Article Information

Corresponding Author: Philip Greenland, MD, Departments of Preventive Medicine and Medicine, Northwestern University Feinberg School of Medicine, 680 N Lake Shore Dr, Ste 1400, Chicago, IL 60611 (p-greenland@northwestern.edu).

Conflict of Interest Disclosures: Dr Greenland reported receiving research grants from the National Institutes of Health and American Heart Association.

References
1.
Whelton  PK, Carey  RM, Aronow  WS,  et al.  2017 ACC/AHA/AAPA/ABC/ACPM/AGS/ APhA/ASH/ASPC/NMA/PCNA guideline for prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.  J Am Coll Cardiol. 2018;71(19):e127-e248. doi:10.1016/j.jacc.2017.11.006PubMedGoogle ScholarCrossref
2.
Leung  AA, Nerenberg  K, Daskalopoulou  SS,  et al; CHEP Guidelines Task Force.  Hypertension Canada’s 2016 Canadian Hypertension Education Program guidelines for blood pressure measurement, diagnosis, assessment of risk, prevention, and treatment of hypertension.  Can J Cardiol. 2016;32(5):569-588. doi:10.1016/j.cjca.2016.02.066PubMedGoogle ScholarCrossref
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National Institute for Health and Clinical Excellence (NICE). Hypertension in adults: diagnosis and management. http://www.nice.org.uk/guidance/CG127. Published August 2011. Updated November 2016. Accessed June 20, 2019.
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Williams  B, Mancia  G, Spiering  W,  et al; ESC Scientific Document Group.  2018 ESC/ESH Guidelines for the management of arterial hypertension.  Eur Heart J. 2018;39(33):3021-3104. doi:10.1093/eurheartj/ehy339PubMedGoogle ScholarCrossref
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Shimamoto  K, Ando  K, Fujita  T,  et al; Japanese Society of Hypertension Committee for Guidelines for the Management of Hypertension.  The Japanese Society of Hypertension Guidelines for the management of hypertension (JSH 2014).  Hypertens Res. 2014;37(4):253-390. doi:10.1038/hr.2014.20PubMedGoogle ScholarCrossref
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Liu  LS, Guan  X, Zhi  BZ; Writing Group of 2010 Chinese Guidelines for the Management of Hypertension.  2010 Chinese guidelines for the management of hypertension  [in Chinese].  Zhonghua Xin Xue Guan Bing Za Zhi. 2011;39(7):579-615.PubMedGoogle Scholar
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Jensen  TS, Chin  J, Ashby  L,  et al. Proposed decision memo for ambulatory blood pressure monitoring (ABPM). Centers for Medicare & Medicaid Services. https://www.cms.gov/medicare-coverage-database/details/nca-proposed-decision-memo.aspx?NCAId=294. Posted April 9, 2019. Accessed June 20, 2019.
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US Preventive Services Task Force. Final recommendation statement: high blood pressure in adults: screening. https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/high-blood-pressure-in-adults-screening. Published October 13, 2015. Accessed June 20, 2019.
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Yang  W-Y, Melgarejo  JD, Thijs  L,  et al.  Office and ambulatory blood pressure with mortality and cardiovascular outcomes  [Published August 6, 2019].  JAMA. doi:10.1001/jama.2019.9811Google Scholar
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