How in-office and ambulatory BP monitoring compare: A systematic review and meta-analysis

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Original Research

How in-office and ambulatory BP monitoring compare: A systematic review and meta-analysis

J Fam Pract. 2017 January;66(1):E5-E12

By

Sergio Reino-Gonzalez, MD, PhD

Salvador Pita-Fernández, MD, PhD

Teresa Seoane-Pillado, PhD

Beatriz López-Calviño, BSc

Sonia Pértega Díaz, PhD

Isolated office BP measurement is insufficient to confirm or rule out poorly controlled hypertension, and it increases the likelihood of under- or overestimating BP control.

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References

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ABSTRACT

Purpose We performed a literature review and meta-analysis to ascertain the validity of office blood pressure (BP) measurement in a primary care setting, using ambulatory blood pressure measurement (ABPM) as a benchmark in the monitoring of hypertensive patients receiving treatment.

Methods We conducted a literature search for studies published up to December 2013 that included hypertensive patients receiving treatment in a primary care setting. We compared the mean office BP with readings obtained by ABPM. We summarized the diagnostic accuracy of office BP with respect to ABPM in terms of sensitivity, specificity, and positive and negative likelihood ratios (LR), with a 95% confidence interval (CI).

Results Only 12 studies met the inclusion criteria and contained data to calculate the differences between the means of office and ambulatory BP measurements. Five were suitable for calculating sensitivity, specificity, and likelihood ratios, and 4 contained sufficient extractable data for meta-analysis. Compared with ABPM (thresholds of 140/90 mm Hg for office BP; 130/80 mmHg for ABPM) in diagnosing uncontrolled BP, office BP measurement had a sensitivity of 81.9% (95% CI, 74.8%-87%) and specificity of 41.1% (95% CI, 35.1%-48.4%). Positive LR was 1.35 (95% CI, 1.32-1.38), and the negative LR was 0.44 (95% CI, 0.37-0.53).

Conclusion Likelihood ratios show that isolated BP measurement in the office does not confirm or rule out the presence of poor BP control. Likelihood of underestimating or overestimating BP control is high when relying on in-office BP measurement alone.

A growing body of evidence supports more frequent use of ambulatory blood pressure monitoring (ABPM) to confirm a diagnosis of hypertension¹ and to monitor blood pressure (BP) response to treatment.² The Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure has long accepted ABPM for diagnosis of hypertension,³ and many clinicians consider ABPM the reference standard for diagnosing true hypertension and for accurately assessing associated cardiovascular risk in adults, regardless of office BP readings.⁴ The US Preventive Services Task Force (USPSTF) recommends obtaining BP measurements outside the clinical setting to confirm a diagnosis of hypertension before starting treatment.⁵ The USPSTF also asserts that elevated 24-hour ambulatory systolic BP is consistently and significantly associated with stroke and other cardiovascular events independent of office BP readings and has greater predictive value than office monitoring.⁵ The USPSTF concludes that ABPM, because of its large evidence base, is the best confirmatory test for hypertension.⁶ The recommendation of the American Academy of Family Physicians is similar to that of the USPSTF.⁷

The challenge. Despite the considerable support for ABPM, this method of BP measurement is still not sufficiently integrated into primary care. And some guidelines, such as those of the European Society of Hypertension, continue to restrict its use in diagnosis and in managing treatment.⁸

Likelihood ratios show that isolated in-office blood pressure measurement does not confirm or rule out poor BP control.

But ABPM’s advantages are numerous. Ambulatory monitors, which can record BP for 24 hours, are typically programmed to take readings every 15 to 30 minutes, providing estimates of mean daytime and nighttime BP and revealing an individual’s circadian pattern of BP.^8-10 Ambulatory BP values usually considered the uppermost limit of normal are 135/85 mm Hg (day), 120/70 mm Hg (night), and 130/80 mm Hg (24 hour).⁸

Office BP monitoring, usually performed manually by medical staff, has 2 main drawbacks: the well-known white-coat effect experienced by many patients, and the relatively small number of possible measurements. A more reliable in-office BP estimation of BP would require repeated measurements at each of several visits.

By comparing ABPM and office measurements, 4 clinical findings are possible: isolated clinic or office (white-coat) hypertension (ICH); isolated ambulatory (masked) hypertension (IAH); consistent normotension; or sustained hypertension. With ICH, BP is high in the office and normal with ABPM. With IAH, BP is normal in the office and high with ABPM. With consistent normotension and sustained hypertension, BP readings with both types of measurement agree.^8,9

In patients being treated for hypertension, ICH leads to an overestimation of uncontrolled BP and may result in overtreatment. The cardiovascular risk, although controversial, is usually lower than in patients diagnosed with sustained hypertension.¹¹ IAH leads to an underestimation of uncontrolled BP and may result in undertreatment; its associated cardiovascular risk is similar to that of sustained hypertension.¹²

Our research objective. We recently published a study conducted with 137 hypertensive patients in a primary care center.¹³ Our conclusion was that in-office measurement of BP had insufficient clinical validity to be recommended as a sole method of monitoring BP control. In accurately classifying BP as controlled or uncontrolled, clinic measurement agreed with 24h-ABPM in just 64.2% of cases.¹³

In our present study, we performed a literature review and meta-analysis to ascertain the validity of office BP measurement in a primary care setting, using ABPM as a benchmark in the monitoring of hypertensive patients receiving treatment.