Arterial hypertension is a leading cause of avoidable mortality in the world. High blood pressure (BP) is known to be associated with cardiovascular disease (CVD) and with the onset of hypertension-mediated organ damage (HMOD), which is an important risk modifier in hypertensive patients.1
International guidelines2,3 recommend home BP monitoring (HBPM) and / or ambulatory BP monitoring (ABPM) for the diagnosis and follow-up of hypertensive patients, due to limitations of in-office BP measurement and greater prognostic value of the 2 former methods. Recent systematic reviews have shown that HBPM and ABPM have similar prognostic value. Both could be used for diagnostic and treatment decision-making in hypertensive patients.4,5
An alternative could be measuring BP without the presence of health care workers, that is, unattended automated office BP measurement (UAOBPM). There is evidence that mean values of repeated measurements taken in a doctor’s office without the presence of an observer for 30 minutes are lower than those of standardized BP measurement, which may suggest benefits of this technique.6 This method of measurement would minimize the alert reaction in the office. Nevertheless, as shown by several authors, it would not disappear.5,7 UAOBPM may be misleading in approximately 40% of hypertensive patients. A study comparing UAOBPM (1 visit, 3 consecutive measurements) with home BP measurements (7 days, 2 measurements in the morning and 2 in the evening) detected “white coat” hypertension in 22.7% of the patients and uncontrolled hypertension in disguise in 15.8% of individuals.8
In the SPRINT (Systolic Blood Pressure Intervention Trial) study,9 where BP was assessed with either UAOBPMs or attended measurements, a greater disparity was perceived between the BP measurement methods (approximately 10 mm Hg lower in UAOBPM). Nonetheless, the patients included in the treatment group had a similarly reduced risk of CVD as the standard group, regardless of BP measurement method.
As far as the prognostic value of UAOBPM goes, numerous studies have been performed to assess the relationship between UAOBPM and HMOD, assessing different parameters (arterial stiffness, retinal arteriolar changes, myocardial damage, pulse wave stiffness, albuminuria, etc.). However, no significant correlations have been observed to date,10-12 probably due to a rare occurrence of HMOD in the analyzed studies. We found no evidence on the relationship between UAOBPM and the onset of CVD.
In this issue of Polish Archives of Internal Medicine, Stopa et al10 compared UAOBPM with in-office BP measurement and its association with HMOD (evaluated using echocardiography, carotid artery ultrasound, pulse wave velocity assessment, and laboratory tests). After 5 minutes of rest (alone or in the presence of staff), 3 consecutive measurements separated by 1 minute each were carried out. Even though UAOBPMs showed significantly lower values for both systolic and diastolic BP, no significant correlation of these BP values with HMOD was noticed.
In addition to the doubts about the prognostic value of UAOBPM, there is currently no universal protocol that defines the number of measurements to be conducted with this technique, nor are the normal values defined. New prospective studies are required to clarify the prognostic value of UAOBPM, the number of measurements to be conducted, and the reference values. Perhaps at present, the implementation of UAOBPM in clinical practice could be justified in the cases of resistant hypertension or the “white coat” effect. It is also true that it entails other limitations, such as the need for more time, the use of specialized equipment, and additional space to perform BP measurements.
In summary, having in mind all the information currently available, the results of the study by Stopa et al10 are not clear. Thus, routine use of UAOBPM for the diagnosis and follow-up of hypertensive patients does not seem advisable. It seems more convenient, for the time being, to use HBPM, which is widely available and not very expensive (50–100 EUR). It should be taken into account that this methods is effective in reducing diagnostic and therapeutic inertia,13 improving adherence to treatment, and the possibility of remote transmission of data.14
One of the major current problems of hypertension is its poor control. Consequently, development of new techniques may help improve outcomes. The HOME BP digital intervention,15 based on self-monitored BP measurements, provided better and more cost-effective control of systolic BP levels after 1 year than a routine care. Considering an enormous potential of mobile device interventions in the management of hypertension, larger-scale studies and research are needed to demonstrate the benefit from these techniques in terms of better control and improved patient prognosis. Home telemonitoring of BP has opened up a new scenario with positive results in terms of both clinical objectives and patient satisfaction. Despite all these, improving the technologic equipment in primary care offices has proven to be necessary for its implementation in clinical practice.
Juan A. Divisón Garrote, MD, PhD, Department of Medicine, Universidad Católica Murcia, Campus Los Jerónimos s/n, 30107 Murcia, Spain, phone: +34 968278800, email: jadivison@telefonica.net
April 5, 2024.
May 7, 2024.
May 28, 2024.
The opinions expressed by the author(s) are not necessarily those of the journal editors, Polish Society of Internal Medicine, or publisher.
None declared.
Divisón Garrote JA, Turégano-Yedro M, Juárez-Gonzálvez P, Pallarés-Carratalá V. More shadows than lights in the blood pressure measurement method? Pol Arch Intern Med. 2024; 134: 16762. doi:10.20452/pamw.16762
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