Preference of blood pressure measurement methods by primary care doctors in Hong Kong: a cross-sectional survey.

BACKGROUND: Hypertension is the most common chronic disease and is the leading cause of morbidity and mortality. Its screening, diagnosis, and management depend heavily on accurate blood pressure (BP) measurement. It is recommended that the diagnosis of hypertension should be confirmed or corroborated by out-of-office BP values, measured using ambulatory BP monitoring (ABPM) and home BP monitoring (HBPM). When office BP is used, automated office BP (AOBP) measurement method, which automatically provides an average of 3-5 BP readings, should be preferred. This study aimed to describe the BP measurement methods commonly used by doctors in primary care in Hong Kong, to screen, diagnose, and manage hypertensive patients. METHODS: In this cross-sectional survey, all doctors registered in the Hong Kong "Primary Care Directory" were mailed a questionnaire, asking their preferred BP-measuring methods to screen, diagnose, and manage hypertensive patients. Furthermore, we also elicited information on the usual number of office BP or HBPM readings obtained, to diagnose or manage hypertension. RESULTS: Of the 1738 doctors included from the directory, 445 responded. Manual measurement using a mercury or aneroid device was found to be the commonest method to screen (63.1%), diagnose (56.4%), and manage (72.4%) hypertension. There was a significant underutilisation of ABPM, with only 1.6% doctors using this method to diagnose hypertension. HBPM was used by 22.2% and 56.8% of the respondents to diagnose and manage hypertension, respectively. A quarter (26.7%) of the respondents reported using only one in-office BP reading, while around 40% participants reported using ≥12 HBPM readings. Doctors with specialist qualification in family medicine were more likely to use AOBP in clinics and to obtain the recommended number of office BP readings for diagnosis and management of hypertension. CONCLUSION: Primary Care doctors in Hong Kong prefer to use manual office BP values, measured using mercury or aneroid devices, to screen, diagnose, and manage hypertension, highlighting a marked underutilisation of AOBP and out-of-office BP measuring techniques, especially that of ABPM. Further studies are indicated to understand the underlying reasons and to minimise the gap between real-life clinical practice and those recommended, based on scientific advances. TRIAL REGISTRATION: Clinicaltrial.gov; ref. no.: NCT03926897.

Measurement of Blood Pressure in Chronic Kidney Disease: Time to Change Our Clinical Practice - A Comprehensive Review.

Chronic kidney disease (CKD) is extremely common all over the world and is strongly linked to cardiovascular disease (CVD). The great majority of CKD patients have hypertension, which raises the risk of cardiovascular disease (CVD), end-stage kidney disease, and mortality. Controlling hypertension in patients with CKD is critical in our clinical practice since it slows the course of the disease and lowers the risk of CVD. As a result, accurate blood pressure (BP) monitoring is crucial for CKD diagnosis and therapy. Three important guidelines on BP thresholds and targets for antihypertensive medication therapy have been published in the recent decade emphasizing the way we measure BP. For both office BP and out-of-office BP measuring techniques, their clinical importance in the management of hypertension has been well defined. Although BP measurement is widely disseminated and routinely performed in most clinical settings, it remains unstandardized, and practitioners frequently fail to follow the basic recommendations to avoid measurement errors. This may lead to misdiagnosis and wrong management of hypertension, especially in CKD patients. Here, we review presently available all BP measuring techniques and their use in clinical practice and the recommendations from various guidelines and research gaps emphasizing CKD patients.

Role of ambulatory blood pressure monitoring in hypertensive patients having controlled office blood pressure.

BACKGROUND AND OBJECTIVES: Ambulatory blood pressure (BP) monitoring has become useful in the diagnosis and management of hypertensive individuals. In this study we tried to know the role of office and ambulatory BP in treated hypertensive patients. METHODS AND PATIENTS: Prospective cohort of 561 treated hypertensive patients were enrolled in the study. Hypertension definitions were according to JNC 8 classification. Office BP and ambulatory BP monitoring was done according to defined protocol. RESULTS: From a subgroup of 158 treated hypertensive patients, 91(16.2%) patients were having white coat hypertension (p value 0.00 by Pearson chi square test). In a subset of 403 patients who were having controlled BP on the day of enrolment as well as on the day of attaching ambulatory BP monitor; 98 (17.4%) patients were having masked uncontrolled hypertension (MUCH). In addition there was very significant percentage of non-dippers and reverse dippers. In our study we found that office BP has a moderate to low specificity and sensitivity and low negative predictive value for overall control in treated hypertensive patients. CONCLUSION: Ambulatory BP monitoring should be included in the management protocol of treated hypertensive patients, for the optimal BP control.

A parallel evaluation of short- and mid-term changes of ambulatory blood pressure in kidney transplant recipients and kidney donors.

Introduction: Kidney transplantation (KTx) is associated with improved blood pressure (BP) levels for kidney transplant recipients (KTRs) without evoking significant changes in donors. However, there is a paucity of studies offering simultaneous detailed evaluation of BP profiles over time in transplant donor-recipient pairs. The aim of the present study was the parallel evaluation of ambulatory BP levels and trajectories in KTRs and their respective living kidney donors in the short and mid-term following KTx. Methods: The study enrolled 40 prospective adult KTRs and their 40 respective donors. All participants were evaluated with 24-h ambulatory BP monitoring (Mobil-O-Graph NG device) at three time points: baseline (1 month before KTx), 3 months and 12 months after KTx. Results: In KTRs, 3-month 24-h systolic BP (SBP) was marginally reduced and 12-month 24-h SBP significantly reduced compared with baseline [131.9 ± 13.3 versus 126.4 ± 11.9 mmHg (P = .075) and 123.9 ± 10.3 mmHg (P = .009),  respectively]. At both the 3- and 12-month time points, 24-h diastolic BP (DBP) was significantly reduced [86.7 ± 11.5 versus 82.2 ± 8.1 mmHg (P = .043) and 80.3 ± 8.5 mmHg (P = .009)]. Similar observations were made for day- and night time SBP and DBP. Repeated-measures analysis of variance (ANOVA) showed a significant gradual decrease over time in mean 24-h SBP [F(1.463, 39.505) = 3.616; P = .049, partial η 2 = 0.118] and DBP [F(1.374, 37.089) = 11.34; P = .055, partial η 2 = 0.116]. In contrast, in kidney donors, 24-h SBP [118.5 ± 11.6 versus 118.2 ± 12.8 mmHg (P = .626) and 119.2 ± 11.4 mmHg (P = .748)] and DBP did not change at 3 or 12 months compared with baseline; repeated measures ANOVA showed no differences in the mean 24-h SBP and DBP levels over time. The number of antihypertensive agents decreas in KTRs and remained stable in donors. Conclusions: KTx reduces ambulatory BP levels and trajectories in KTRs at 3 months and further so at 12 months post-surgery. Kidney donation does not affect the ambulatory BP levels and trajectories of donors at the same intervals.

Sources of automatic office blood pressure measurement error: a systematic review.

Objective: Accurate and reliable blood pressure (BP) measurement is important for the prevention and treatment of hypertension. The oscillometric-based automatic office blood pressure measurement (AOBPM) is widely used in hospitals and clinics, but measurement errors are common in BP measurements. There is a lack of systematic review of the sources of measurement errors.Approach: A systematic review of all existing research on sources of AOBPM errors. A search strategy was designed in six online databases, and all the literature published before October 2021 was selected. Those studies that used the AOBPM device to measure BP from the upper arm of subjects were included.Main results: A total of 1365 studies were screened, and 224 studies were included in this final review. They investigated 22 common error sources with clinical AOBPM. Regarding the causes of BP errors, this review divided them into the following categories: the activities before measurement, patient's factors, measurement environment, measurement procedure, and device settings. 13 sources caused increased systolic and diastolic BP (SBP and DBP), 2 sources caused the decrease in SBP and DBP, only 1 source had no significant effect on BPs, and the other errors had a non-uniform effect (either increase or decrease in BPs). The error ranges for SBP and DBP were -14 to 33 mmHg and -6 to 19 mmHg, respectively.Significance: The measurement accuracy of AOBPM is susceptible to the influence of measurement factors. Interpreting BP readings need to be treated with caution in clinical measurements. This review made comprehensive evidence for the need for standardized BP measurements and provided guidance for clinical practitioners when measuring BP with AOBPM devices.

Office blood pressure measurement: A comprehensive review.

The conventional auscultatory methods for measuring blood pressure have been used to screen, diagnose, and manage hypertension since long. However, these have been found to be prone to errors especially the white coat phenomena which cause falsely high blood pressure readings. The Mercury sphygmomanometer and the Aneroid variety are no longer recommended by WHO for varying reasons. The Oscillometric devices are now recommended with preference for the Automated Office Blood Pressure measurement device which was found to have readings nearest to the Awake Ambulatory Blood Pressure readings. The downside for this device is the cost barrier. The alternative is to use the simple oscillometric device, which is much cheaper, with the rest and isolation criteria of the SPRINT study. This too may be difficult due to space constraints and the post-clinic blood measurement is a new concept worth further exploration.

Hipertensão mascarada: qual a importância da mrpa neste contexto? / Masked hypertension: how important is hbpm in this context?

A hipertensão arterial (HA) é o principal fator contributivo para as doenças cardiovasculares, as quais constituem a mais importante causa de morte prevenível no mundo. A falta de conhecimento da população acerca da doença, e consequentemente de um diagnóstico adequado, torna baixo o número de pessoas que se tratam. O aspecto silencioso da HA, e a má adesão ao tratamento proposto, dentre outros fatores, contribuem para o elevado risco de complicações. A medida da pressão arterial (PA) neste contexto apresenta grande importância não apenas no diagnóstico, mas também no acompanhamento de portadores de HA, podendo ser realizada de forma casual, em consultório, ou fora do mesmo com a utilização de outros métodos para tal. Dentre as medidas de PA, a monitorização residencial da PA (MRPA) se destaca. É um método destinado a fazer registro da PA fora do ambiente de consultório, obedecendo a um protocolo previamente estabelecido e normatizado. Além disto, a MRPA apresenta custos menores do que a monitorização ambulatorial da PA (MAPA). De acordo com a atual Diretriz Brasileira de HA, são considerados anormais valores de PA consultório ≥ 140/90 mmHg e de MRPA ≥ 130/80 mmHg. Sob esta perspectiva, a MRPA é um exame que permite que se faça o diagnóstico de HA verdadeira (PA elevada no consultório e na MRPA), normotensão verdadeira (PA normal no consultório e na MRPA), HA do avental branco (HAB) (PA elevada no consultório e normal na MRPA) e HA mascarada (HM) (PA normal no consultório e elevada na MRPA). O diagnóstico de HM é bastante relevante na prática clínica, pois em termos prognósticos, a HM apresenta um risco cardiovascular maior que a HAB e a normotensão verdadeira. Além disto, a incidência de eventos cardiovasculares na HM é similar ou até superior à da HA verdadeira.

Hypertension is the main contributing factor to cardiovascular diseases, which are the most important cause of death in the world. The lack of proper diagnosis, mainly due to the silent aspect of hypertension, makes the rate of people undergoing treatment low, contributing to the high risk of complications. The measurement of blood pressure (BP) in this context is important not only in the diagnosis, but also in the follow-up of patients with hypertension, and it can be performed casually, in the office, or outside the office, using other methods for this purpose. Home blood pressure monitoring (HBPM) is a method designed to record BP outside the office environment, following a previously established and standardized protocol and has a lower cost than ambulatory blood pressure monitoring (ABPM) According to the current Brazilian hypertension guideline, office BP values ≥ 140/90 mmHg and HBPM values ≥ 130/80 mmHg are considered abnormal. From this perspective, HBPM is a test that allows the diagnosis of true hypertension (high BP in the office and in HMBP), true normotension (normal BP in the office and in the HBPM), white coat hypertension (high BP in the office and normal BP in HBPM) and masked hypertension (normal BP in the office and high in HBPM). The diagnosis of masked hypertension is quite relevant in clinical practice, because this phenotype has greater cardiovascular risk than true normotension and white coat hypertension. On the other hand, the incidence of cardiovascular events is similar or even greater in masked hypertension in comparison with true hypertension.