Hipertens riesgo vasc. 2011;28(4):149—153

www.elsevier.es/hipertension

REVISIÓN

Home blood pressure monitoring: application in clinical practice

G.S. Stergiou ∗, A. Kollias, E.G. Nasothimiou

Hypertension Center, Third University Department of Medicine, Sotiria Hospital, Athens, Greece

Received 30 March 2011; accepted 30 March 2011Available online 15 June 2011

KEYWORDSHome blood pressure;Self-measurement;Diagnosis;Treatment;White coathypertension;Masked hypertension

Abstract Because of the white coat and the masked hypertension phenomena out-of-officeblood pressure measurement using ambulatory (ABPM) or home monitoring (HBPM) is oftenrequired for the accurate diagnosis and treatment decision. ABPM has been extensivelyinvestigated, whereas only recently convincing evidence on the prognostic and diagnosticability of HBPM has been accumulated. Both methods provide multiple measurements inthe usual environment of each individual and have similar ability to detect the white coatand masked hypertension phenomena in both untreated and treated hypertensives. However,HBPM is more widely available, better accepted by patients and less costly, and there-fore more appropriate for long-term application. For reliable HBPM validated electronic armdevices with automated memory and the recommended monitoring schedule should be used(7 days, duplicate morning and evening measurements; average after discarding the first day).HBPM is a valuable tool for the optimal management of most subjects with elevated bloodpressure.© 2011 SEHLELHA. Published by Elsevier España, S.L. All rights reserved.

PALABRAS CLAVEPresión arterial endomicilio;Auto-medición;Diagnóstico;Tratamiento;Hipertensión de batablanca;Hipertensiónenmascarada

Monitorización de la presión arterial en el domicilio: aplicación en la práctica clínica

Resumen Debido al síndrome de la bata blanca y a los fenómenos de hipertensión enmas-carada, a menudo es necesario realizar una medición de la presión arterial de forma ambulatoria(MAPA) o domiciliaria que permita obtener un diagnóstico preciso y decidir el mejor tratamiento.Si bien la monitorización ambulatoria de la presión arterial ha sido ampliamente investigada,la automedición de la presión arterial en domicilio (AMPA) no contaba hasta recientemente conpruebas convincentes sobre su capacidad de pronóstico y diagnóstico. Los dos métodos pro-porcionan mediciones múltiples de la PA dentro el entorno habitual del paciente y tienen unacapacidad similar para detectar el síndrome de la bata blanca y la hipertensión enmascarada,

tanto en hipertensos no tratados como en aquellos bajo tratamiento. No obstante, la AMPA esmás asequible, está mejor aceptada por los pacientes y resulta menos costosa, por lo que esmás apropiada para su uso a largo plazo. Para obtener una AMPA fiable solo es necesario utilizardispositivos electrónicos de brazo validados, que cuenten con memoria automatizada, y quelas mediciones se lleven a cabo mediante el programa recomendado (7 días, con mediciones demanana y noche duplicadas, y la obtención de un promedio tras descartar las mediciones del

∗ Corresponding author.E-mail address: gstergi@med.uoa.gr (G.S. Stergiou).

1889-1837/$ – see front matter © 2011 SEHLELHA. Published by Elsevier España, S.L. All rights reserved.doi:10.1016/j.hipert.2011.03.007

150 G.S. Stergiou et al

primer día). La AMPA es una herramienta valiosa para la adecuada gestión de la mayoría de lossujetos con hipertensión arterial.

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he need of out-of-office blood pressureeasurement

he conventional measurement of blood pressure by theoctor in the office has been regarded as the cornerstoneor the diagnosis of hypertension and the assessment of theffects of antihypertensive drug treatment.1 However, officelood pressure measurement can often be misleading mainlyue the white coat and the masked hypertension phenom-na, the poor reproducibility of office measurements, thelacebo effect and the observer bias.1—3 Assessment of bloodressure out of the office using either 24 hour ambulatory orelf-home monitoring is often needed and has been shown torovide more reliable information, leading thereby to moreccurate diagnosis and more appropriate treatment.1—3

In contrast to ambulatory blood pressure monitoring thatn the last two decades has been extensively studied and hasstablished its role as a valuable technique that improveshe management of hypertension,1 research in home bloodressure monitoring has been delayed by longer than oneecade and only in 2008 major position papers from theS and Europe have fully endorsed this method for widepplication in the hypertensive population.1—3

ome blood pressure monitoring: advantagesnd limitations

ome blood pressure monitoring is a valuable tool for thenitial assessment of subjects with elevated blood pressure,ainly because it allows the detection of the white-coat

nd the masked hypertension phenomena.2—4 Moreover,ome monitoring is valuable in the long-term follow upf treated hypertensives. Apart from the detection of thehite-coat and the masked hypertension phenomena, whichre also common in treated hypertensives, home monitor-ng provides a more reliable evaluation of the efficacy ofntihypertensive drugs as well as the duration of effecty assessing the ratio of morning to evening home bloodressure.2—4 Moreover, it allows the detection of excessivelood pressure-lowering effect in treated individuals. Moremportantly, the use of home monitoring has been shown tomprove patients’ compliance with treatment and therebyhe control rates of hypertension. Finally, home monitor-ng has the potential to reduce the costs of health-care ofypertensive patients.

In order to take full advantage of the method andrevent potential problems associated with its use, homelood pressure monitoring should only be performed afteratients’ education and training, (which is less when elec-

ronic devices are used) and under medical supervision.owever, there are still limitations because some patientsake overuse of the method and the random blood pres-

ure fluctuation might cause unnecessary anxiety.2—4 More

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r Elsevier España, S.L. Todos los derechos reservados.

mportantly some patients may make self-adjustment ofrug treatment which should be strongly discouraged.

ome versus ambulatory blood pressureonitoring

ome blood pressure monitoring is similar to 24 hour ambu-atory monitoring because both methods provide multipleeasurements away from the office or clinic setting in the

sual environment of each individual and under routine dailyonditions.2—4 However, these methods also have importantifferences because home measurements are taken only inhe sitting posture, after a few minutes rest, and always atome, whereas ambulatory monitoring is performed duringarious routine daily conditions (walking, standing, sitting,ying), without a period of rest before each measurement,nd at home, at work and during sleep.2—4 Despite theseifferences, home and ambulatory blood pressure appear toave similar advantages, in terms of reproducibility, abil-ty to diagnose the white coat and masked hypertensionhenomena and to predict target organ damage and car-iovascular events.2—5 Moreover, studies have found similarlood pressure levels with home and awake ambulatoryeasurement and therefore the use of the same normalcy

hreshold (<135/85 mm Hg) is applied for both methods.2,3

ecause of their differences home and ambulatory monitor-ng appear to be complementary rather than competitiveethods and when used in combination provide a more

omplete picture of the individual’s blood pressure profile.quipment availability, cost of use and patients’ preferencere important factors that influence the decision on whichethod to prefer each time (fig. 1), yet all these factors

avor the use of home monitoring. In general, ambulatoryonitoring appears to be more suitable for the initial assess-ent of elevated blood pressure whereas home monitoring isore suitable for the long-term follow up of treated hyper-

ension (fig. 1).4

ome blood pressure monitoring in childrennd adolescents

lthough ambulatory blood pressure monitoring has firmlystablished its role and is regarded as indispensable forhe accurate diagnosis of hypertension in the pediatricopulation,6 the evidence on the clinical utility of homelood pressure monitoring is limited.7 Preliminary evi-ence favouring the use of the method has been recentlyublished7 and reference values (percentiles of home bloodressure for gender and age) are now available8 andndorsed by recent guidelines.6 Interestingly, in children

nd adolescents the relationship between home and day-ime ambulatory blood pressure is not the same as in thedults with daytime ambulatory blood pressure being sig-ificantly higher than home measurements, probably due to

Home blood pressure monitoring: application in clinical practice 151

Office BP > 120 mmHg

Ambulatoryor home

BP monitoring

Agreementbetween office and

ambulatory/home BP

Initially: prefer ambulatoryBP monitoring

Follow-up: prefer homeBP monitoring

Select accordingly to:- Device availability- Patient’s preference

Select accordingly to:- Device availability- Patient’s preference

Disagreementbetween office and

ambulatory/home BP

Repeatout-of-office BP

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Stergiou GS, 2011.Treat according to

ambulatory/home BP

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Figure 1 Strategy for implementing office and out-of-o

the high level of physical activity of children during the day.7

Two studies have shown similar diagnostic performance ofhome measurements in terms of white coat, masked andsustained hypertension in children as in the adults.9,10 Thus,home blood pressure monitoring appears to have consider-able potential in the assessment of elevated blood pressurein children. However, until more studies including ambula-tory blood pressure monitoring and target damage becomeavailable treatment decisions based solely on home mea-surements should be discouraged.7

Home blood pressure monitoring, treatmentcompliance and hypertension control

Because of the wide use of home blood pressure monitor-ing in the population, and the suitability and acceptanceof this method by the hypertensive patients for the long-term follow up, there is potential for this method to improvecompliance with treatment and thereby the control rate ofhypertension. A review of trials investigating the effect ofhome blood pressure monitoring on medication complianceconcluded that this method is effective particularly whenapplied in combination with other adherence-enhancingstrategies.11 A Cochrane review of 72 trials showed thathome blood pressure monitoring is one of the few effec-tive interventions aiming to improve blood pressure controlin patients with hypertension.12 Moreover, a meta-analysisof trials involving 2,714 hypertensive subjects showed thatthe use of self-home blood pressure monitoring is associ-ated with 10% greater chance of achieving optimal bloodpressure control.13 This difference in blood pressure con-trol might appear to be small, yet if applied in the entirepopulation of hypertensive subjects is expected to havean important impact on cardiovascular disease prevention.The wide availability of home monitors in the populationhas the additional potential to detect undiagnosed hyper-

tension and improve awareness. Moreover, several studiesthat applied modern home blood pressure tele-monitoringtechniques aiming to improve blood pressure control havereported encouraging results.

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blood pressure (BP) measurements in clinical practice.

It is important to note that, despite the wide use ofome monitoring in many countries, its cost-effectivenessas not been thoroughly investigated. Home blood pres-ure monitoring has the potential for significant costavings through the prevention of unnecessary treatmentn untreated or treated subjects with white coat phe-omenon, the lesser need for office visits, and the optimalreatment of untreated and treated masked hypertensives,hich is expected to reduce the incidence of cardiovas-ular complications. Preliminary data have been favorableor the cost-effectiveness of home monitoring. Eventually,n many countries hypertensive patients have decided toover themselves the cost of applying this method by pur-hasing their own devices, as indicated by the large salesf home blood pressure monitors worldwide.14,15 A recentall-to-action statement by the American Heart Association-merican Society of Hypertension recommended that, as it

s the case with home monitoring of glucose in diabetes,ome blood pressure monitoring should be prescribed byealthcare providers and the cost of the method (devicend training) should be reimbursed.2

ome blood pressure monitoring schedule,eliability and standardization

everal studies have looked at the optimal home bloodressure monitoring schedule required for a reliable assess-ent. There is a consensus between European and American

uidelines that home blood pressure should be monitoredor 7 days of measurements (not less than 3 days), withuplicate morning (before drug intake if treated) andvening measurements on each day and that the aver-ge should be calculated after discarding the readingsf the first day.1—3 Average home blood pressure higherhan 135/85 mm Hg (systolic/ diastolic) is regarded asigh, lower than 130/80 mm Hg low, and intermediate val-

es borderline.1—3 For the long-term follow up of treatedypertension performing no more than 1-2 measurementser week is recommended. Home monitoring should beerformed using validated electronic arm devices (for

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pdated lists of validated devices see www.bhsoc.org andww.dableducational.org).

When decision making for treatment is based on homelood pressure measurements an important requisite is tonsure that a reliable assessment of the blood pressure atome is made. Several studies have shown that hypertensiveatients often misreport (over or under-report their homelood pressure values).16—18 Therefore, standardization ofome monitoring (recommended schedule) and objectiveeporting (automated memory or PC link) is essential to pre-ent bias and misreporting, as it is currently the case withmbulatory monitoring that provides an unbiased assess-ent of the blood pressure profile (the patient cannot

hoose the time and number of measurements or selecthe readings to report).4 These requirements can easilye fulfilled by current technology of blood pressure moni-ors software with minimal increase in the cost. This is anssential prerequisite for physicians to rely on home bloodressure measurements in making treatment decisions inlinical practice.

ome blood pressure monitoring: applicationn clinical practice

onvincing evidence on the prognostic ability of homelood pressure monitoring and its clinical usefulness forhe initial diagnosis and the long-term follow-up of treatedypertension is now available.2—5 Thus, recent Europeannd American guidelines have endorsed the wide applica-ion of this method in the management of hypertensionn clinical practice.2,3 The evidence on the usefulness ofome blood pressure monitoring suggests that this methodhould be applied in most subjects with possible or treatedypertension.2—4

The detection of masked hypertension remains a contro-ersial issue in terms of which subjects should be screenednd is not addressed in the proposed strategies.4,19 Sub-ects with borderline office blood pressure levels (officelood pressure higher than 120/80 mmHg in two or moreisits), or elevated office blood pressure normalized inepeated measurement, as well as those at high totalardiovascular risk and all treated hypertensives wouldrobably benefit from home blood pressure monitoring.4,19

n cases with disagreement between office and home mea-urements (white coat or masked hypertension), becausef the imperfect reproducibility of both methods a repeatome blood pressure monitoring session or ambulatory mon-toring is required in order to confirm diagnosis.4,20,21 Atrategy for implementing office and out-of-office bloodressure measurements in clinical practice is presentedn Figure 1.

For the long-term follow-up of treated hypertension,ome blood pressure monitoring clearly is the optimalethod because of its wider availability, lower cost and

etter acceptance by patients for repeated use comparedo ambulatory blood pressure monitoring.2—4 The evidencehowing improvement of patients’ compliance and hyper-ension control rates by implementing home blood pressureonitoring are additional strong arguments for implement-

ng this method in all treated hypertensives.2—4

G.S. Stergiou et al

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21. Stergiou GS, Salgami EV, Tzamouranis DG, Roussias LG. Maskedhypertension assessed by ambulatory blood pressure versushome blood pressure monitoring: is it the same phenomenon?Am J Hypertens. 2005;18:772—8.