What email address or phone number would you like to use to sign in to Docs.com?
If you already have an account that you use with Office or other Microsoft services, enter it here.
Or sign in with:
Signing in allows you to download and like content, and it provides the authors analytical data about your interactions with their content.
Embed code for: Home monitoring of blood pressure
Select a size
16 VOLUME 38 : NUMBER 1 : FEBRUARY 2015 Full text free online at www.australianprescriber.com Home monitoring of blood pressure SUMMARY Home blood pressure monitoring is the self-measurement of blood pressure by patients. In the diagnosis and management of high blood pressure it is complementary to 24-hour ambulatory blood pressure monitoring and clinic blood pressure measurements. Home monitoring can also help to identify white-coat and masked hypertension. Home monitoring has good reproducibility, is well tolerated and relatively inexpensive. It is superior to blood pressure taken in the clinic in predicting cardiovascular events and mortality. Twice-daily measurements are recommended, usually in the morning and evening for a minimum of five days. The threshold for defining hypertension is an average home blood pressure of 135/85 mmHg or above. Patients are engaged with their management when they monitor their own blood pressure. This results in increased adherence to therapy and lower blood pressure. predict hypertensive end-organ disease,9-12 and are stronger predictors for cardiovascular events and mortality.13-16 Several international guidelines recommend using home blood pressure monitoring for hypertension diagnosis, evaluation of suspected white-coat hypertension and masked hypertension, and for guiding management.7,17-19 Substantial evidence for the benefits of home blood pressure monitoring comes from studies in Japan.19 Method The blood pressure measurements are recorded by the patient using a validated, automated blood pressure device. Devices with a storage memory have advantages over self-recording for ensuring the validity of measurements. Home blood pressure is optimal when the patient takes readings while seated, around the same time each morning and evening. Monitoring is usually over a period of one week, with a five day minimum. Standing blood pressures can also be measured if needed to assess postural changes in blood pressure. The patient should sit quietly (no talking or distractions such as television) for five minutes in a comfortable ambient temperature. The blood pressure cuff selected should be appropriate for body size. Feet should be flat on the floor, legs uncrossed, upper arm bare, back and arm supported with the cuff at heart level. Readings should not be taken if the patient feels uncomfortable, stressed or in pain. Smoking or caffeine drinks are to be avoided for 30 minutes before the measurement. Readings should be done before eating or taking medication. Two readings are taken one minute apart with the Introduction Blood pressure measurements taken by a doctor are often higher than the patient’s usual blood pressure. Uncertainty surrounding a patient’s blood pressure outside the doctor’s office is a recognised barrier to treating hypertension in Australian general practice.1 This uncertainty can be alleviated by using 24-hour ambulatory blood pressure monitoring.2,3 An alternative is to instruct the patient to measure their own blood pressure for several days. This home blood pressure monitoring is more likely to reflect the patient’s underlying blood pressure, than measurements in the clinic. Rationale for home monitoring An Australian consensus statement has promoted 24-hour ambulatory blood pressure monitoring as the reference standard for optimal care in uncomplicated hypertension.2 However, home blood pressure monitoring has better reproducibility.4-6 Compared with 24-hour ambulatory blood pressure monitoring, home monitoring is less expensive, much more widely available and provides information about the day-to- day variability of blood pressure.7 An advantage of 24-hour ambulatory blood pressure monitoring is the detection of nocturnal hypertension or ‘non-dipping’ blood pressure patterns, which are associated with a worse prognosis.8 However, newer devices for home blood pressure monitoring may enable nocturnal measurements. At this stage the two methods should be considered as complementary clinical tools. Compared to clinic measurements, home measurements are more reproducible, more strongly Barry P McGrath Adjunct professor of medicine Monash University Medical lead National Test Centre Australian Medical Council Melbourne Key words blood pressure, hypertension, patient compliance, self-monitoring Aust Prescr 2015;38:16–9 DIAGNOSTIC TESTS This article has a continuing professional development activity for pharmacists available at www.australianprescriber.com/ continuing-professional- development 17Full text free online at www.australianprescriber.com VOLUME 38 : NUMBER 1 : FEBRUARY 2015 Blood pressure variability Home blood pressure monitoring is a good method for assessing long-term variability in blood pressure. Increased variability and episodic hypertension have been shown to have adverse consequences in patients with stroke or transient cerebral ischaemia.30,31 Moreover, different drug classes may have different effects on variability. This is an important area for further research. Assessing treatment Home blood pressure monitoring provides a reliable estimate of the effectiveness of antihypertensive treatment,32 and the measurements are relatively unaffected by placebo.33 Therapy guided by home blood pressure monitoring compared with usual care can lead to better blood pressure control and higher patient satisfaction with medical care.33,34 Additional support for the patient such as educational materials or counselling increases the benefit.35 Home blood pressure monitoring can also be used to assess the duration of the antihypertensive effect and identify hypertension that is resistant to treatment.36 Adherence Home blood pressure monitoring engages the patient in their management and increases adherence to therapy.37-40 This can lead to a lower blood pressure than standard care.37,38 However, home blood pressure monitoring was not as successful at improving adherence to treatment in primary care as it was in hospital-based or non-clinical (community centre/ workplace) settings.41 Additional support strategies may be needed in primary care. Cost-effectiveness Most home blood pressure monitoring devices are relatively cheap (approximately $100), reliable and widely available. There are also lending schemes in some general practice and specialist clinics. Home monitoring has been shown to be cost neutral, after taking into account the number of consultations, drugs, referrals, equipment and training expenses.42 It is cost-effective in terms of reducing the drugs needed to maintain blood pressure control.43 Telemonitoring of the measurements may be more costly, although this may be offset by having better healthcare outcomes.44 Adverse effects Some patients with anxiety may become stressed about their readings, particularly if these are high, and this may affect subsequent measurements. Then there are those patients who change their treatment according to readings without medical consultation, second reading being recorded in a diary or electronic spreadsheet. The average measurement over the monitoring period is used to determine the patient’s underlying blood pressure. An average weekly home blood pressure above 135/85 mmHg is considered to be the cut point for hypertension. White-coat hypertension White-coat hypertension is defined as a blood pressure of at least 140/90 mmHg measured at the doctor’s office on at least three occasions, but with a normal blood pressure measured outside the office. An average weekly home blood pressure below 135/85 mmHg or two 24-hour ambulatory blood pressure recordings with daytime ambulatory blood pressure below 135/85 mmHg would rule out the diagnosis of hypertension. The population prevalence of white-coat hypertension is approximately 15%.20 It is more common in women and non-smokers and is associated with increased waist circumference, glucose intolerance, and increased left ventricular mass.20,21 White-coat hypertension is a risk factor for sustained hypertension22 with 36% of patients progressing to established hypertension within five years. Those who progress are more likely to have a higher waist circumference, a higher plasma glucose two hours post-loading and an increased resting aorto-femoral pulse wave velocity. Patients with white-coat hypertension have a significantly increased risk of developing type 2 diabetes.23-25 This highlights the importance of monitoring and managing the cardiovascular risk in white-coat hypertension, particularly glucose intolerance and obesity, and not just the blood pressure alone. Masked hypertension Masked hypertension is defined as a blood pressure in the clinic below 140/90 mmHg, but high blood pressure elsewhere, for example a blood pressure of 135/85 mmHg or more on home monitoring. The population prevalence is 10–17%,7 but may be up to 29% in untreated patients with diabetes.26 These patients commonly have subclinical cardiovascular disease and the risk for incident cardiovascular events is similar to that of sustained hypertension.27-29 A particular at-risk group are patients with obstructive sleep apnoea. Thorough assessment of cardiovascular risk is key to managing masked hypertension. In addition to home monitoring, management will require 24-hour ambulatory blood pressure monitoring if there is nocturnal hypertension or non-dipping. DIAGNOSTIC TESTS 18 Full text free online at www.australianprescriber.com VOLUME 38 : NUMBER 1 : FEBRUARY 2015 Home monitoring of blood pressure The author wishes to acknowledge colleagues listed below who he has been working with as an expert panel, looking at developing a set of guidelines for Australian doctors and health professionals involved in management of patients with hypertension. This summary article has drawn significantly on the work undertaken by the group. Professor James Sharman, Dr Faline Howes and Professor Mark Nelson, Menzies Research Institute Tasmania, University of Tasmania, Hobart Professor Geoffrey Head and Professor Markus Schlaich, Baker IDI Heart and Diabetes Institute, Melbourne Professor Michael Stowasser, University of Queensland School of Medicine, Greenslopes and Princess Alexandra Hospitals, Brisbane Alison Wilson, National Heart Foundation of Australia, Melbourne Professor Paul Glasziou, Centre for Research in Evidence Based Practice, Bond University, Queensland increasing the risk of adverse consequences. Others may become obsessed and perform excessive numbers of readings. Conclusion Ambulatory blood pressure monitoring is the current gold standard for assessing hypertension. Home blood pressure monitoring is a complementary method. Hypertension is diagnosed if the average of twice-daily measurements for at least five days is 135/85 mmHg or higher. Home blood pressure monitoring can help to detect patients who have white-coat or masked hypertension. As the price of blood pressure monitors reduces, home monitoring by patients will become a routine part of their management. An Australian consensus statement on the role of home blood pressure monitoring is being prepared. Conflict of interest: none declared SELF-TEST QUESTIONS True or false? 3. Home blood pressure monitoring provides less information than 24-hour ambulatory monitoring about the day-to-day variability in blood pressure. 4. Home blood pressure monitoring cannot distinguish between white-coat hypertension and masked hypertension. Answers on page 35 DIAGNOSTIC TESTS 1. Howes F, Hansen E, Williams D, Nelson M. Barriers to diagnosing and managing hypertension - a qualitative study in Australian general practice. Aust Fam Physician 2010;39:511-6. 2. Head GA, McGrath BP, Mihailidou AS, Nelson MR, Schlaich MP, Stowasser M, et al. Ambulatory blood pressure monitoring in Australia: 2011 consensus position statement. J Hypertens 2012;30:253-66. 3. Hypertension: Clinical management of primary hypertension in adults. National Institute for Health and Care Excellence. 2011. www.nice.org.uk/nicemedia/live/13561/56008/56008.pdf [cited 2015 Jan 7] 4. Stergiou GS, Baibas NM, Gantzarou AP, Skeva II, Kalkana CB, Roussias LG, et al. Reproducibility of home, ambulatory, and clinic blood pressure: implications for the design of trials for the assessment of antihypertensive drug efficacy. Am J Hypertens 2002;15:101-4. 5. Warren RE, Marshall T, Padfield PL, Chrubasik S. Variability of office, 24-hour ambulatory, and self-monitored blood pressure measurements. Br J Gen Pract 2010;60:675-80. 6. Ragot S, Genes N, Vaur L, Herpin D. Comparison of three blood pressure measurement methods for the evaluation of two antihypertensive drugs: feasibility, agreement, and reproducibility of blood pressure response. Am J Hypertens 2000;13:632-9. 7. Mancia G, Fagard R, Narkiewicz K, Redón J, Zanchetti A, Böhm M, et al. 2013 ESH/ESC Guidelines for the management of arterial hypertension: the Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). J Hypertens 2013;31:1281-357. 8. Hansen TW, Li Y, Boggia J, Thijs L, Richart T, Staessen JA. Predictive role of the nighttime blood pressure. Hypertension 2011;57:3-10. 9. Tsunoda S, Kawano Y, Horio T, Okuda N, Takishita S. Relationship between home blood pressure and longitudinal changes in target organ damage in treated hypertensive patients. Hypertens Res 2002;25:167-73. 10. Mule G, Caimi G, Cottone S, Nardi E, Andronico G, Piazza G, et al. Value of home blood pressures as predictor of target organ damage in mild arterial hypertension. J Cardiovasc Risk 2002;9:123-9. 11. Gaborieau V, Delarche N, Gosse P. Ambulatory blood pressure monitoring versus self-measurement of blood pressure at home: correlation with target organ damage. J Hypertens 2008;26:1919-27. 12. Tachibana R, Tabara Y, Kondo I, Miki T, Kohara K. Home blood pressure is a better predictor of carotid atherosclerosis than office blood pressure in community- dwelling subjects. Hypertens Res 2004;27:633-9. 13. Imai Y, Ohkubo T, Sakuma M, Tsuji II, Satoh H, Nagai K, et al. Predictive power of screening blood pressure, ambulatory blood pressure and blood pressure measured at home for overall and cardiovascular mortality: a prospective observation in a cohort from Ohasama, northern Japan. Blood Press Monit 1996;1:251-4. 14. Ohkubo T, Imai Y, Tsuji I, Nagai K, Kato J, Kikuchi N, et al. Home blood pressure measurement has a stronger predictive power for mortality than does screening blood pressure measurement: a population-based observation in Ohasama, Japan. J Hypertens 1998;16:971-5. 15. Sega R, Facchetti R, Bombelli M, Cesana G, Corrao G, Grassi G, et al. Prognostic value of ambulatory and home blood pressures compared with office blood pressure in the general population: follow-up results from the Pressioni Arteriose Monitorate e Loro Associazioni (PAMELA) study. Circulation 2005;111:1777-83. 16. Ward AM, Takahashi O, Stevens R, Heneghan C. Home measurement of blood pressure and cardiovascular disease: systematic review and meta-analysis of prospective studies. J Hypertens 2012;30:449-56. 17. Parati G, Stergiou GS, Asmar R, Bilo G, de Leeuw P, Imai Y, et al. European Society of Hypertension practice guidelines for home blood pressure monitoring. J Hum Hypertens 2010;24:779-85. 18. Daskalopoulou SS, Khan NA, Quinn RR, Ruzicka M, McKay DW, Hackam DG, et al. The 2012 Canadian hypertension education program recommendations for the management of hypertension: blood pressure measurement, diagnosis, assessment of risk, and therapy. Can J Cardiol 2012;28:270-87. 19. Imai Y, Kario K, Shimada K, Kawano Y, Hasebe N, Matsuura H, et al. The Japanese Society of Hypertension guidelines for self-monitoring of blood pressure at home (second edition). Hypertens Res 2012;35:777-95. 20. Niiranen TJ, Jula AM, Kantola IM, Reunanen A. Prevalence and determinants of isolated clinic hypertension in the Finnish population: the Finn-HOME study. J Hypertens 2006;24:463-70. 21. Martin CA, McGrath BP. White-coat hypertension. Clin Exp Pharmacol Physiol 2014;41:22-9. 22. Ugajin T, Hozawa A, Ohkubo T, Asayama K, Kikuya M, Obara T, et al. White-coat hypertension as a risk factor for the development of home hypertension: the Ohasama study. Arch Intern Med 2005;165:1541-6. REFERENCES 19Full text free online at www.australianprescriber.com VOLUME 38 : NUMBER 1 : FEBRUARY 2015 DIAGNOSTIC TESTS DIAGNOSTIC TESTS 23. Hosaka M, Mimura A, Asayama K, Ohkubo T, Hayashi K, Kikuya M, et al. Relationship of dysregulation of glucose metabolism with white-coat hypertension: the Ohasama study. Hypertens Res 2010;33:937-43. 24. Martin CA, Cameron JD, Chen SS, McGrath BP. Two hour glucose post loading: a biomarker of cardiovascular risk in isolated clinic hypertension. J Hypertens 2011;29:749-57. 25. Mancia G, Bombelli M, Facchetti R, Madotto F, Quarti-Trevano F, Grassi G, et al. Increased long-term risk of new-onset diabetes mellitus in white-coat and masked hypertension. J Hypertens 2009;27:1672-78. 26. Franklin SS, Thijs L, Li Y, Hansen TW, Boggia J, Liu Y, et al. Masked hypertension in diabetes mellitus: treatment implications for clinical practice. Hypertension 2013;61:964-71. 27. Fagard RH, Cornelissen VA. Incidence of cardiovascular events in white-coat, masked and sustained hypertension versus true normotension: a meta-analysis. J Hypertens 2007;25:2193-8. 28. Pierdomenico SD, Cuccurullo F. Prognostic value of white- coat and masked hypertension diagnosed by ambulatory monitoring in initially untreated subjects: an updated meta analysis. Am J Hypertens 2011;24:52-8. 29. Bobrie G, Clerson P, Menard J, Postel-Vinay N, Chatellier G, Plouin PF. Masked hypertension: a systematic review. J Hypertens 2008;26:1715-25. 30. Rothwell PM. Limitations of the usual blood-pressure hypothesis and importance of variability, instability, and episodic hypertension. Lancet 2010;375:938-48. 31. Hashimoto T, Kikuya M, Ohkubo T, Satoh M, Metoki H, Inoue R, et al. Home blood pressure level, blood pressure variability, smoking, and stroke risk in Japanese men: the Ohasama study. Am J Hypertens 2012;25:883-91. 32. Metoki H, Ohkubo T, Kikuya M, Asayama K, Inoue R, Obara T, et al. The velocity of antihypertensive effect of losartan/hydrochlorothiazide and angiotensin II receptor blocker. J Hypertens 2012;30:1478-86. 33. Imai Y, Ohkubo T, Hozawa A, Tsuji I, Matsubara M, Araki T, et al. Usefulness of home blood pressure measurements in assessing the effect of treatment in a single-blind placebo- controlled open trial. J Hypertens 2001;19:179-85. 34. Magid DJ, Olson KL, Billups SJ, Wagner NM, Lyons EE, Kroner BA. A pharmacist-led, American Heart Association Heart360 web-enabled home blood pressure monitoring program. Circ Cardiovasc Qual Outcomes 2013;6:157-63. 35. Uhlig K, Patel K, Ip S, Kitsios GD, Balk EM. Self-measured blood pressure monitoring in the management of hypertension: a systematic review and meta-analysis. Ann Intern Med 2013;159:185-94. 36. Imai Y, Ohkubo T, Kikuya M, Hashimoto J. Practical aspect of monitoring hypertension based on self-measured blood pressure at home. Intern Med 2004;43:771-8. 37. Edmonds D, Foerster E, Groth H, Greminger P, Siegenthaler W, Vetter W. Does self-measurement of blood pressure improve patient compliance in hypertension? J Hypertens Suppl 1985;3:S31-4. 38. Omvik P, Gerhardsen G. The Norwegian office-, home-, and ambulatory blood pressure study (NOHA). Blood Press 2003;12:211-9. 39. Marquez-Contreras E, Martell-Claros N, Gil-Guillen V, de la Figuera-Von Wichmann M, Casado-Martinez JJ, Martin-de Pablos JL, et al. Efficacy of a home blood pressure monitoring programme on therapeutic compliance in hypertension: the EAPACUM-HTA study. J Hypertens 2006;24:169-75. 40. Halme L, Vesalainen R, Kaaja M, Kantola I; HOme MEasuRement of blood pressure study group. Self- monitoring of blood pressure promotes achievement of blood pressure target in primary health care. Am J Hypertens 2005;18:1415-20. 41. Ogedegbe G, Schoenthaler A. A systematic review of the effects of home blood pressure monitoring on medication adherence. J Clin Hypertens (Greenwich) 2006;8:174-80. 42. McManus RJ, Mant J, Roalfe A, Oakes RA, Bryan S, Pattison HM, et al. Targets and self monitoring in hypertension: randomised controlled trial and cost effectiveness analysis. BMJ 2005;331:493. 43. Verberk WJ, Kroon AA, Lenders JW, Kessels AG, van Montfrans GA, Smit AJ, et al. Self-measurement of blood pressure at home reduces the need for antihypertensive drugs: A randomized, controlled trial. Hypertension 2007;50:1019-25. 44. Omboni S, Gazzola T, Carabelli G, Parati G. Clinical usefulness and cost effectiveness of home blood pressure telemonitoring: meta-analysis of randomized controlled studies. J Hypertens 2013;31:455-67; discussion 467-8. Melbourne: Therapeutic Guidelines Limited; 2014 419 pages Electronic version also available The strength of this guideline is its concise and yet thorough approach to the management of the more common endocrinological conditions. For example, strategies for the different types of diabetes are explained in great detail. The guidance for diabetic ketoacidosis and hyperosmolar hyperglycaemia is excellent. The numerous tables provided throughout the book are useful and easy to read. However, there are areas of weakness. There are too many cross references throughout the book, making it difficult to read in parts. Reference to further information in the electronic version of the Therapeutic Guidelines, eTG, is common. This is problematic as not every user has access to the electronic version. I do think a guide needs to be able to stand alone. The recommendations about blood glucose monitoring are too vague and generalised. Also, the advice on sunlight exposure for patients with vitamin D deficiency lacks detail. Despite some shortcomings, overall I think this book is excellent. I like its pocket size format, and the treatment recommendations are detailed, practical and easy to follow. I recommend this endocrinology guide to health practitioners working in a hospital or in general practice. Heinz Tilenius GP Melbourne Book review Therapeutic Guidelines: Endocrinology. Version 5. 12;25:883-91. 32. Metoki H, Ohkubo T, Kikuya M, Asayama K, Inoue R, Obara T, et al. The velocity of antihypertensive effect of losartan/hydrochlorothiazide and angiotensin II receptor blocker. J Hypertens 2012;30:1478-86. 33. Imai Y, Ohkubo T, Hozawa A, Tsuji I, Matsubara M, Araki T, et al. Usefulness of home blood pressure measurements in assessing the effect of treatment in a single-blind placebo- controlled open trial. J Hypertens 2001;19:179-85. 34. Magid DJ, Olson KL, Billups SJ, Wagner NM, Lyons EE, Kroner BA. A pharmacist-led, American Heart Association Heart360 web-enabled home blood pressure monitoring program. Circ Cardiovasc Qual Outcomes 2013;6:157-63. 35. Uhlig K, Patel K, Ip S, Kitsios GD, Balk EM. Self-measured blood pressure monitoring in the management of hypertension: a systematic review and meta-analysis. Ann Intern Med 2013;159:185-94. 36. Imai Y, Ohkubo T, Kikuya M, Hashimoto J. Practical aspect of monitoring hypertension based on self-measured blood pressure at home. Intern Med 2004;43:771-8. 37. Edmonds D, Foerster E, Groth H, Greminger P, Siegenthaler W, Vetter W. Does self-measurement of blood pressure improve patient compliance in hypertension? J Hypertens Suppl 1985;3:S31-4. 38. Omvik P, Gerhardsen G. The Norwegian office-, home-, and ambulatory blood pressure study (NOHA). Blood Press 2003;12:211-9. 39. Marquez-Contreras E, Martell-Claros N, Gil-Guillen V, de la Figuera-Von Wichmann M, Casado-Martinez JJ, Martin-de Pablos JL, et al. Efficacy of a home blood pressure monitoring programme on therapeutic compliance in hypertension: the EAPACUM-HTA study. J Hypertens 2006;24:169-75. 40. Halme L, Vesalainen R, Kaaja M, Kantola I; HOme MEasuRement of blood pressure study group. Self- monitoring of blood pressure promotes achievement of blood pressure target in primary health care. Am J Hypertens 2005;18:1415-20. 41. Ogedegbe G, Schoenthaler A. A systematic review of the effects of home blood pressure monitoring on medication adherence. J Clin Hypertens (Greenwich) 2006;8:174-80. 42. McManus RJ, Mant J, Roalfe A, Oakes RA, Bryan S, Pattison HM, et al. Targets and self monitoring in hypertension: randomised controlled trial and cost effectiveness analysis. BMJ 2005;331:493. 43. Verberk WJ, Kroon AA, Lenders JW, Kessels AG, van Montfrans GA, Smit AJ, et al. Self-measurement of blood pressure a